Anatomy Vol-I Vishram Singh

TEXTBOOK OF ANATOMY
UPPER LIMB AND THORAX
TEXTBOOK OF ANATOMY
UPPER LIMB AND THORAX
Volume I
Second Edition
Vishram Singh, MS, PhD

Professor and Head, Department of Anatomy
Professor-in-Charge, Medical Education Unit
Santosh Medical College, Ghaziabad
Editor-in-Chief, Journal of the Anatomical Society of India
Member, Academic Council and Core Committee PhD Course, Santosh University
Member, Editorial Board, Indian Journal of Otology
Medicolegal Advisor, ICPS, India
Consulting Editor, ABI, North Carolina, USA
Formerly at: GSVM Medical College, Kanpur
King Georges Medical College, Lucknow
Al-Arab Medical University, Benghazi (Libya)
All India Institute of Medical Sciences, New Delhi
ELSEVIER
A division of
Reed Elsevier India Private Limited
Textbook of Anatomy: Upper Limb and Thorax, Volume I, 2e

Vishram Singh
2014 Reed Elsevier India Private Limited
First edition 2010
Second edition 2014
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Dedicated to
My Mother
Late Smt Ganga Devi Singh Rajput
an ever guiding force in my life for achieving knowledge through education
My Wife
Mrs Manorama Rani Singh
for tolerating my preoccupation happily during the preparation of this book
My Children
Dr Rashi Singh and Dr Gaurav Singh
for helping me in preparing the manuscript
My Teachers
Late Professor (Dr) AC Das
for inspiring me to be multifaceted and innovative in life
Professor (Dr) A Halim
for imparting to me the art of good teaching
My Students, Past and Present
for appreciating my approach to teaching anatomy and
transmitting the knowledge through this book
Preface to the
Second Edition
It is with great pleasure that I express my gratitude to all students and teachers who appreciated, used, and recommended the
first edition of this book. It is because of their support that the book was reprinted three times since its first publication in
2009.
The huge success of this book reflects appeal of its clear, unclustered presentation of the anatomical text supplemented by
perfect simple line diagrams, which could be easily drawn by students in the exam and clinical correlations providing the
anatomical, embryological, and genetic basis of clinical conditions seen in day-to-day life in clinical practice.
Based on a large number of suggestions from students and fellow academicians, the text has been extensively revised. Many
new line diagrams and halftone figures have been added and earlier diagrams have been updated.
I greatly appreciate the constructive suggestions that I received from past and present students and colleagues for
improvement of the content of this book. I do not claim to absolute originality of the text and figures other than the new mode
of presentation and expression.
Once again, I whole heartedly thank students, teachers, and fellow anatomists for inspiring me to carry out the revision. I
sincerely hope that they will find this edition more interesting and useful than the previous one. I would highly appreciate
comments and suggestions from students and teachers for further improvement of this book.
To learn from previous experience and change
accordingly, makes you a successful man.
Vishram Singh
Preface to the
First Edition
This textbook on upper limb and thorax has been carefully planned for the first year MBBS students. It follows the revised
anatomy curriculum of the Medical Council of India. Following the current trends of clinically-oriented study of Anatomy,
I have adopted a parallel approach that of imparting basic anatomical knowledge to students and simultaneously providing
them its applied aspects.
To help students score high in examinations the text is written in simple language. It is arranged in easily understandable
small sections. While anatomical details of little clinical relevance, phylogenetic discussions and comparative analogies have
been omitted, all clinically important topics are described in detail. Brief accounts of histological features and developmental
aspects have been given only where they aid in understanding of gross form and function of organs and appearance of common
congenital anomalies. The tables and flowcharts summarize important and complex information into digestible knowledge
capsules. Multiple choice questions have been given chapter-by-chapter at the end of the book to test the level of understanding
and memory recall of the students. The numerous simple 4-color illustrations further assist in fast comprehension and
retention of complicated information. All the illustrations are drawn by the author himself to ensure accuracy.
Throughout the preparation of this book one thing I have kept in mind is that anatomical knowledge is required by clinicians
and surgeons for physical examination, diagnostic tests, and surgical procedures. Therefore, topographical anatomy relevant
to diagnostic and surgical procedures is clinically correlated throughout the text. Further, Clinical Case Study is provided at
the end of each chapter for problem-based learning (PBL) so that the students could use their anatomical knowledge in clinical
situations. Moreover, the information is arranged regionally since while assessing lesions and performing surgical procedures,
the clinicians encounter region-based anatomical features. Due to propensity of fractures, dislocations and peripheral nerve
lesions in the upper limb there is in-depth discussion on joints and peripheral nerves.
As a teacher, I have tried my best to make the book easy to understand and interesting to read. For further improvement of
this book I would greatly welcome comments and suggestions from the readers.
Vishram Singh
Acknowledgments
At the outset, I express my gratitude to Dr P Mahalingam, CMD; Dr Sharmila Anand, DMD; and Dr Ashwyn Anand, CEO,
Santosh University, Ghaziabad, for providing an appropriate academic atmosphere in the university and encouragement
which helped me in preparing this book.
I am also thankful to Dr Usha Dhar, Dean Santosh Medical College for her cooperation. I highly appreciate the good
gesture shown by Dr PK Verma, Dr Ruchira Sethi, Dr Deepa Singh, and Dr Preeti Srivastava for checking the nal proofs.
I sincerely thank my colleagues in the Department, especially Professor Nisha Kaul and Dr Ruchira Sethi for their assistance.
I gratefully acknowledge the feedback and support of fellow colleagues in Anatomy, particularly,
Professors AK Srivastava (Head of the Department) and PK Sharma, and Dr Punita Manik, King Georges Medical College,
Lucknow.
Professor NC Goel (Head of the Department), Hind Institute of Medical Sciences, Barabanki, Lucknow.
Professor Kuldeep Singh Sood (Head of the Department), SGT Medical College, Budhera, Gurgaon, Haryana.
Professor Poonam Kharb, Sharda Medical College, Greater Noida, UP.
Professor TC Singel (Head of the Department), MP Shah Medical College, Jamnagar, Gujarat.
Professor TS Roy (Head of the Department), AIIMS, New Delhi.
Professors RK Suri (Head of the Department), Gayatri Rath, and Dr Hitendra Loh, Vardhman Mahavir Medical College and
Safdarjang Hospital, New Delhi.
Professor Veena Bharihoke (Head of the Department), Rama Medical College, Hapur, Ghaziabad.
Professors SL Jethani (Dean and Head of the Department), and RK Rohtagi, Dr Deepa Singh and Dr Akshya Dubey,
Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun.
Professors Anita Tuli (Head of the Department), Shipra Paul, and Shashi Raheja, Lady Harding Medical College, New Delhi.
Professor SD Joshi (Dean and Head of the Department), Sri Aurobindo Institute of Medical Sciences, Indore, MP.
Lastly, I eulogize the patience of my wife Mrs Manorama Rani Singh, daughter Dr Rashi Singh, and son Dr Gaurav Singh
for helping me in the preparation of this manuscript.
I would also like to acknowledge with gratitude and pay my regards to my teachers Prof AC Das and Prof A Halim and
other renowned anatomists of India, viz. Prof Shamer Singh, Prof Inderbir Singh, Prof Mahdi Hasan, Prof AK Dutta, Prof
Inder Bhargava, etc. who inspired me during my student life.
I gratefully acknowledge the help and cooperation received from the staff of Elsevier, a division of Reed Elsevier India Pvt.
Ltd., especially Ganesh Venkatesan (Director Editorial and Publishing Operations), Shabina Nasim (Senior Project ManagerEducation Solutions), Goldy Bhatnagar (Project Coordinator), and Shrayosee Dutta (Copy Editor).
Vishram Singh
Contents
Preface to the Second Edition
vii
Preface to the First Edition
ix
Acknowledgments
xi
Chapter 1
Introduction to the Upper Limb
Chapter 2
Bones of the Upper Limb
10
Chapter 3
Pectoral Region
34
Chapter 4
Axilla (Armpit)
48
Chapter 5
Back of the Body and Scapular Region
58
Chapter 6
Shoulder Joint Complex (Joints of Shoulder Girdle)
72
Chapter 7
Cutaneous Innervation, Venous Drainage and Lymphatic Drainage of the Upper Limb
83
Chapter 8
Arm
92
Chapter 9
Forearm
105
Chapter 10
Elbow and Radio-ulnar Joints
126
Chapter 11
Hand
137
Chapter 12
Joints and Movements of the Hand
161
Chapter 13
Major Nerves of the Upper Limb
172
Chapter 14
Introduction to Thorax and Thoracic Cage
185
Chapter 15
Bones and Joints of the Thorax
196
Chapter 16
Thoracic Wall and Mechanism of Respiration
211
Chapter 17
Pleural Cavities
227
Chapter 18
Lungs (Pulmones)
234
Chapter 19
Mediastinum
249
xiv
Contents
Chapter 20
Pericardium and Heart
256
Chapter 21
Superior Vena Cava, Aorta, Pulmonary Trunk, and Thymus
283
Chapter 22
Trachea and Esophagus
292
Chapter 23
Thoracic Duct, Azygos and Hemiazygos Veins, and Thoracic Sympathetic Trunks
302
Multiple Choice Questions
311
Index
325
CHAPTER
Introduction to the
Upper Limb
The upper limb is the organ of the body, responsible for

manual activities. It is freely movable, especially its distal
segmentthe hand, which is adapted for grasping and
manipulating the objects.
A brief description of comparative anatomy of the limbs
would facilitate understanding of their structure and
function.
All the terrestrial vertebrates possess four limbsa pair of
forelimbs and a pair of hindlimbs. In quadrupeds such as
dogs and buffaloes, both forelimbs and hindlimbs are
evolved for transmission of body weight and locomotion. In
human beings, due to evolution of erect posture, the function
of weight bearing and locomotion is performed only by the
hind limbs (lower limbs), while upper limbs are spared for
prehensile/manipulative activities, such as grasping, holding,
picking, etc. (Fig. 1.1).
There are three types of grips: (a) power grip, (b) hook
grip, and (c) precision grip. The power and hook grips are
primitive in nature, hence found in higher primates. The
precision grip is characteristic of human beings hence only
humans can properly hold a pen, pencil, needles,
instruments, etc. As a result, human beings could make
advancements in arts, craft, and technology, of course, with
the help of intelligence.
To suit the prehensile activities, the following changes
took place in the upper limbs of humans during evolution:
Forelimbs
Hindlimbs
A
Upper limb
(forelimb)
1. Appearance of joints permitting rotatory movements of

the forearm, viz. supination and pronation.
2. Addition of clavicle to act as a strut and keep upper limb
away from the body for prehension.
3. Rotation of thumb to 90 for opposition.
4. Suitable changes for free mobility of the fingers and
hand.
N.B. The human hand with its digits can perform complex
skilled movements under the control of the brain. Hence man
is considered as the master mechanic of the animal world.
The disabling effects of an injury to the upper limb, particularly
Lower limbs
(hindlimbs)
Fig. 1.1 Position of limbs: A, in quadrupeds; B, in humans.
Textbook of Anatomy: Upper Limb and Thorax
that of hand is far more than the extent of an injury. Therefore,

a sound understanding of its structure and functions is of
great clinical significancethe ultimate aim of treating any
ailment of the upper limb being to restore its function.
The upper limbs are connected to the trunk by a pectoral

girdle. The limb girdle is defined as the bones which connect
the limbs to the axial skeleton. The pectoral girdle is
composed of two bones scapula and clavicle. The scapula is
connected to the clavicle by the acromioclavicular joint, and
the clavicle is attached to the axial skeleton by the
sternoclavicular joint. The pectoral girdle is not a complete
girdle because it is attached to the axial skeleton only
anteriorly. The primary function of the pectoral girdle is to
provide attachment to numerous muscles, which move the
arm and forearm. It is not weight bearing and is, therefore,
more delicate as compared to the pelvic girdle. Note that
pelvic girdle is a complete girdle.
Clavicle
Shoulder
Scapula
Arm
(brachium)
Humerus
N.B. Only one small joint (sternoclavicular joint) connects

the skeleton of upper limb to the rest of the skeleton of the
body.
PARTS OF THE UPPER LIMB

For descriptive purposes, the upper limb is divided into the
following four parts (Fig. 1.2):
1.
2.
3.
4.
Shoulder.
Arm or brachium.
Forearm or antebrachium.
Hand.
The shoulder region includes: (a) axilla or armpit,

(b) scapular region or parts around the scapula (shoulder
blade), and (c) pectoral or breast region on the front of the
chest.
The bones of the shoulder region are the clavicle (collar
bone) and the scapula (shoulder blade). They articulate with
each other at the acromioclavicular joint and form the
shoulder girdle. The shoulder girdle articulates with the rest
of the skeleton of the body only at the small sternoclavicular
joint.
The arm is the part of the upper limb between the
shoulder and elbow (or cubitus). The bone of the arm is
humerus, which articulates with the scapula at the
shoulder joint and upper ends of radius and ulna at the
elbow joint.
The forearm is the part of the upper limb between the
elbow and the wrist. The bones of the forearm are radius and
ulna. These bones articulate with humerus at the elbow joint
and with each other forming radio-ulnar joints.
The hand (or manus) consists of the following parts:
(a) wrist or carpus, (b) hand proper (or metacarpus), and
(c) digits (thumb and fingers).
Ulna
Forearm
(antebrachium)
Radius
Carpus (wrist)
Metacarpus
Hand
Phalanges
Fig. 1.2 Parts of the upper limb.
The wrist consists of eight carpal bones arranged in two

rows, each consisting of four bones. The carpal bones
articulate (a) with each other at intercarpal joints,
(b) proximally with radius forming radio-carpal wrist
joint, and (c) distally with metacarpal bones at
carpometacarpal joints.
Table 1.1 Parts of the upper limb

Part
Subdivisions
Shoulder region
Pectoral region
Axilla
Scapular region
Bones
Clavicle
Scapula
Arm
Humerus
Forearm
Hand
Joints
Sternoclavicular
Acromioclavicular
Shoulder
Radius
Ulna
Elbow
Radio-ulnar
Wrist (carpus)
Carpal bones
Wrist/radio-carpal
Intercarpal
Hand proper (metacarpus)
Metacarpal bones
Carpometacarpal
Intermetacarpal
Digits
Phalanges
Metacarpophalangeal
Proximal and distal interphalangeal
The hand proper consists of five metacarpal bones

numbered one to five from lateral to medial side in
anatomical position. They articulate (a) proximally with
distal row of carpal bones forming carpometacarpal
joints, (b) with each other forming intermetacarpal joints,
and (c) distally with proximal phalanges forming
metacarpophalangeal joints.
The digits are five and numbered 1 to 5 from lateral to
medial side. The first digit is called thumb and remaining
four digits are fingers. Each digit is supported by three
short long bonesthe phalanges except thumb, which is
supported by only two phalanges. The phalanges form
metacarpophalangeal joints with metacarpals and
interphalangeal joints with one another. The first
carpometacarpal joint has a separate joint cavity hence
movements of thumb are much more free than that of any
digit/finger.
N.B. The functional value of thumb is immense. For
example, in grasping, the functional value of thumb is equal
to other four digits/fingers. Therefore, loss of thumb alone is
as disabling as the loss of all four fingers.
The subdivisions, bones and joints of different parts of

the upper limb are summarized in Table 1.1.
COMPARISON AND CONTRAST BETWEEN

THE UPPER AND LOWER LIMBS
Both the upper and lower limbs are built on the same basic
principle. Each limb is made up of two portions: proximal
and distal.
The proximal part is called limb girdle and attaches the
limb to the trunk. The distal part is free and consists of
proximal, middle, and distal segments, which are referred to
as arm, forearm, and hand respectively in the upper limb,

and thigh, leg, and foot respectively in the lower limb. The
homologous parts of the upper and lower limbs are
enumerated in Table 1.2.
A short account of the development of the limbs further
makes it easier to understand the differences between the
upper and lower limbs (Fig. 1.3).
The development of upper and lower limbs begins in the
4th week of intrauterine life (IUL). A pair of small elevations
appears on the ventrolateral aspect of the embryo called limb
buds. The anterior pair of the upper limb buds appears
opposite the lower cervical segments. The posterior pair of
lower limb buds appears 3 or 4 days later at the level of
lumbar and upper sacral segments. Thus during an early
stage of development all the four limbs appear as paired limb
buds. First they are simple flipper-like appendages so that the
upper and lower limbs are similar in their appearance. Each
has dorsal and ventral surfaces, and preaxial and postaxial
borders. The preaxial border faces towards the head. Later in
Table 1.2 Homologous parts of the upper and lower limbs
Upper limb
Lower limb
Shoulder/pectoral girdle
Shoulder joint
Arm
Elbow joint
Forearm
Wrist joint
Hand
(a) Carpus
(b) Metacarpus
(c) Fingers*
Hip girdle/pelvic girdle

Hip joint
Thigh
Knee joint
Leg
Ankle joint
Foot
(a) Tarsus
(b) Metatarsus
(c) Toes*
*First digit in hand is termed thumb and first digit in foot is termed great
toe.
Upper
limb bud
Thumb
90 lateral
rotation
Thumb
Big toe
Lower
limb bud
Big toe
90 medial rotation
Fig. 1.3 Development of the limbs.
Table 1.3 Differences between the upper and lower limbs

Upper limb
Lower limb
Function
Prehension (i.e., manipulation of objects by

grasping)
Locomotion and transmission of weight
Bones
Smaller and weaker
Larger and stronger
Joints
Smaller and less stable
Larger and more stable
Muscles
Smaller and attached to smaller bony areas

Antigravity muscles less developed
Larger and attached to larger bony areas

Antigravity muscles more developed
Girdle
Pectoral girdle
(a) Made up of two bones, clavicle and scapula
(b) No articulation with vertebral column
(c) Articulation with axial skeleton is very small
through sternoclavicular joint
Pelvic girdle
(a) Made up of single bone, the hip bone*
(b) Articulates with vertebral column
(c) Articulation with axial skeleton is large, through
sacroiliac joint
Preaxial border
Faces laterally
Faces medially
*The hip bone essentially consists of three components: ilium, ischium, and pubis, which later fuse to form a single bone.
the development, the ends of limb buds become expanded

and flattened to form the hand and foot plates in which the
digits develop. The digits nearest to the preaxial border are
thumb and big toe in the upper and lower limbs, respectively.
The limbs then rotate.
The lower limb buds rotate medially through 90 so that
their preaxial border faces medially and their extensor
surface faces forwards. The upper limb buds on the other
hand rotate laterally through 90 so that their preaxial border
faces laterally their extensor surface faces backwards.
The differences between the upper and lower limbs are
listed in Table 1.3.
TRANSMISSION OF FORCE IN THE

UPPER LIMB (Fig. 1.4)
The pectoral girdle on each side consists of two bones:
clavicle and scapula, only clavicle is attached to the rest of
skeleton by a small jointthe sternoclavicular joint. The two
bones of girdle are joined together by even smaller joint, the
acromioclavicular joint. The clavicle is attached to the
scapula by a strong coracoclavicular ligament (strongest
ligament in the upper limb), and the clavicle is anchored to
the 1st costal cartilage by the costoclavicular ligament.
Coracoclavicular
ligament
Clavicle
Sternoclavicular
joint
Forces of the upper limb are transmitted to the axial

skeleton by clavicle through costoclavicular ligament and
sternoclavicular joint. The lines of force transmission in the
upper limb are shown in Flowchart 1.1.
Acromioclavicular
joint
BONES OF THE UPPER LIMB

They are already described with parts of the upper limb (for
details see Page 2).
Costoclavicular
ligament
MUSCLES OF THE UPPER LIMB
Scapula
The muscles of upper limb include (a) the muscles that

attach the limb and girdle to the body and (b) the muscles of
arm, forearm, and hand. The deltoid muscle covers the
shoulder like a hood and is commonly used for intramuscular
injections.
The arm and forearm are invested in the deep fascia like a
sleeve and are divided into anterior and posterior
compartments by intermuscular septa. The muscles of
anterior and posterior compartments mainly act
synergistically to carry out specific functions. The muscles of
anterior compartment are mainly flexors and those of
posterior compartment extensors.
The muscles of hand are responsible for its various skilled
movements such as grasping, etc.
Humerus
Humero-ulnar joint
Ulna
Radius
Interosseous
membrane
NERVES OF THE UPPER LIMB (Fig. 1.5)

The nerve supply to the upper limb is derived from the
brachial plexus (formed by ventral rami of C5 to C8 and T1
spinal nerves). The five main branches of brachial plexus
are axillary, musculocutaneous, median, ulnar, and radial
nerves.
Fig. 1.4 Transmission of force in the upper limb.
The axillary nerve supplies the deltoid and teres minor

muscles.
Clavicle
Sternoclavicular joint
and
costoclavicular ligament
Coracoclavicular ligament
Humerus
Radius
Wrist joint
Inte
ro
mem sseous
bran
e
Shoulder joint
Elbow joint
Ulna
Hand
Force
Flowchart 1.1 Lines of force transmission in the upper limb.
Scapula
Axial skeleton
Axillary nerve
Musculocutaneous
nerve
Radial nerve
Radial nerve
Median nerve
Ulnar nerve
Ulnar nerve
Deep branch of
radial nerve
(posterior interosseous
nerve)
Deep branch of
radial nerve
(posterior interosseous
nerve)
Superficial branch of
radial nerve
(superficial
radial nerve)
Fig. 1.5 Main nerves of the upper limb. A, anterior aspect; B, posterior aspect.
The musculocutaneous, median, and ulnar nerves supply

the muscles of anterior (flexor) compartments of the arm
and forearm.
The radial nerve supplies the muscles of the posterior
(extensor) compartments of the arm and forearm.
N.B. All the intrinsic muscles of the hand are supplied by

the ulnar nerve except muscles of thenar eminence and first
two lumbricals.
The axillary is the continuation of subclavian artery. At

the lower border of the teres major muscle its name is
changed to brachial artery. The brachial artery continues
down the arm and just distal to the elbow joint, it divides
into radial and ulnar arteries, which follow the bones, after
which they are named. In the hand, radial artery terminates
by forming the deep palmar arch and ulnar artery terminates
by forming the superficial palmar arch.
ARTERIES OF THE UPPER LIMB (Fig. 1.6)
The blood to the upper limb is supplied by four main

arteries: axillary, brachial, radial, and ulnar.
The axillary artery supplies the shoulder region.

The brachial artery supplies the anterior and posterior
compartments of the arm.
The radial and ulnar arteries supply the lateral and medial
parts of the forearm, respectively.
Common carotid artery

Subclavian artery
Brachiocephalic artery/trunk
Axillary artery
Profunda brachii artery
Brachial artery
Radial artery
Ulnar artery
Deep palmar arch

Superficial palmar arch
Fig. 1.6 Arteries of the upper limb.
VEINS OF THE UPPER LIMB

The deep veins of the upper limb follow the arteries and run
superiorly towards the axilla, where axillary vein travels
superiorly and becomes subclavian vein at the outer border
of the 1st rib. The subclavian vein continues towards the root
of the neck where it joins the internal jugular vein to form
the brachiocephalic vein. The two brachiocephalic veins
(right and left) join each other to form superior vena cava,
which drains into the heart.
The superficial veins of the upper limb originate from
the dorsal venous arch of the hand. The lateral end of the
dorsal venous arch forms the cephalic vein, which runs
along the lateral aspect of the upper limb and terminates
into the axillary vein in the axilla. The medial end of the
dorsal venous arch forms the basilic vein, which ascends
along the medial aspect of the upper limb and empties into
the axillary vein as well. Anterior to the elbow, the cephalic
vein is connected to the basilic vein via the median cubital
vein.
LYMPHATICS OF THE UPPER LIMB

The lymphatics of the upper limb originate in the hand. The
superficial lymph vessels follow the superficial veins. The
deep lymph vessels follow the deep arteries (viz. radial, ulnar,
and brachial) and pass superiorly to the axilla where they
drain into the axillary lymph nodes.
Clinical correlation
Injuries of the upper limb: The human upper limb is
meant for prehension, i.e., grasping, and not for locomotion
and transmission of weight. The mechanism of grasping is
provided by hand with the four fingers flexing against the
opposable thumb. The upper limb is therefore light built,
i.e., its bones are smaller and weaker, joints are smaller
and less stable, etc. Hence, it is more prone to injuries
such as dislocation, fractures, etc.
Dislocations: The common dislocations in the upper
limb are dislocations of shoulder joint (most commonly
dislocated joint in the body), elbow joint, and lunate
bone of the hand.
Fractures: The common fractures in the upper limb
are fracture of clavicle (most commonly fractured
bone in the body), humerus, radius, and scaphoid.
The scaphoid is the most commonly fractured bone of
the hand.
Nerve injuries: The common nerve injuries in the upper

limb are injuries of brachial plexus, median nerve, radial
nerve, and ulnar nerve. The compression of median
nerve at wrist is most common peripheral neuropathy in
the body. The three major nerves of the upper limb (e.g.,
radial, median, and ulnar) have predilection of
involvement in leprosy. The ulnar nerve can be easily
palpated behind the medial epicondyle of the humerus.
Sites for the intramuscular and intravenous injections:
The intramuscular injection is most commonly given in
the shoulder region in deltoid muscle;
intravenous injection is most commonly given in the
superficial veins in front of elbow and the dorsum of
hand.
Sites for feeling arterial pulsations: The arterial pulsation
is most commonly felt and auscultated on the medial side
of the front of elbow for recording of blood pressure. The
arterial pulse is most commonly felt on the lateral side of
the front of distal forearm of recording pulse rate.
Golden Facts to Remember

" Most important function of hand
Prehension (i.e., grasping)
" Most important feature of human hand
Opposition of thumb and precision grip
" Only point of bony contact between the upper

limb and chest
" Part of the upper limb having largest

representation in the brain
Hand
" Most important digit of the hand
Thumb
CHAPTER
The study of bones of the upper limb is important to

understand the general topography of the upper limb and
the attachment of various muscles and ligaments. The
students must read the features and attachments of the bones
before undertaking the study of the upper limb.
The study of bones also helps to understand the position
of various articulations, wide range of the movements
executed by the upper limb and the genesis of various
fractures, which are common in the upper limb bones.
Each upper limb contains 32 bones (Fig. 2.1), viz.

Clavicle (1)
Shoulder joint
Sternoclavicular
joint
Scapula (1)
Scapula, the shoulder blade (1). Bones of the pectoral

Clavicle, the collar bone (1).
girdle
Humerus, the bone of arm (1).
Radius and ulna, the bones of forearm (2).
Carpal bones, the bones of wrist (8).
Metacarpals, the bones of hand (5).
Phalanges, the bones of digits (fingers) (14).
Humerus (1)
Elbow joint
CLAVICLE
The clavicle (L. clavicle = key) or collar bone is the long bone,
with a slight S-shaped curve. It is located horizontally on the
anterior aspect of the body at the junction of root of the neck
and trunk. It articulates medially with the sternum and 1st
rib cartilage and laterally with the acromion process of the
scapula. It is subcutaneous and hence it can be palpated
through its entire extent. It is the only bony attachment
between the trunk and upper limb.
Ulna (1)
Radius (1)
Wrist joint
Carpal bones (8)

Metacarpals (5)
FUNCTIONS
The functions of the clavicle are as follows:
1. It acts as a strut for holding the upper limb far from the
trunk so that it can move freely. This allows free swing of
the upper limb for various prehensile acts such as
holding, catching, etc.
Phalanges (14)
Fig. 2.1 Bones of the upper limb.
2. It transmits forces from the upper limb to the axial

skeleton (sternum).
3. It provides an area for the attachment of muscles.
PECULIARITIES
Shaft
The shaft is curved. Its medial two-third is round and convex
forwards, and its lateral one-third is flattened and concave
forwards. The inferior surface of the shaft possesses a small
longitudinal groove in its middle third.
The peculiar features of the clavicle are as follows:

1.
2.
3.
4.
It is the only long bone which lies horizontally.

It has no medullary cavity.
It is subcutaneous throughout its extent.
It is the first bone to start ossifying (between the fifth
and sixth week of intrauterine life) and last bone to
complete its ossification (at 25 years).
5. It is the only long bone which ossifies by two primary
centers.
6. It is the only long bone which ossifies in membrane
except for its medial end (cf. long bones ossify in
cartilage).
7. It may be pierced through and through by cutaneous
nerve (intermediate supraclavicular nerve).
PARTS
The clavicle consists of three parts: two ends (medial and
lateral) and a shaft (Fig. 2.2):
Ends
1. The lateral (acromial) end is flattened above downwards
and articulates with medial margin of the acromion
process.
2. The medial (sternal) end is enlarged and quadrilateral.
It articulates with the clavicular notch of the manubrium
sterni.
ANATOMICAL POSITION AND SIDE DETERMINATION

The side of clavicle can be determined by holding the bone
horizontally in such a way that its flattened end is on the
lateral side and its enlarged quadrilateral end is on the
medial side. The convexity of its medial two-third and
concavity of its lateral one-third face forwards with
longitudinal groove in the middle third of shaft facing
inferiorly.
FEATURES AND ATTACHMENTS (Fig. 2.3)

Lateral End/Acromial End
It is flattened above downwards. An oval facet on this end
articulates with the facet on the medial margin of the
acromion to form acromioclavicular joint. The lateral end
provides attachment to fibrous capsule of acromioclavicular
joint.
Medial End/Sternal End
The enlarged medial end has a saddle-shaped articular
surface, which articulates with the clavicular notch of
manubrium sterni to form sternoclavicular joint. It provides
attachment to (a) fibrous capsule (b) articular disc, and
(c) interclavicular ligament.
Post.
Sternal end
Med.
Lat.
Acromial end
Ant.
A
Trapezoid ridge
Shaft
Post.
Conoid
tubercle
Acromial end
Sternal end
Med.
Lat.
Ant.
Subclavian groove
(groove for
subclavius muscle)
Fig. 2.2 Right clavicle: A, superior aspect; B, inferior aspect.
Rough impression for

costoclavicular ligament
11
12
Trapezius
Sternocleidomastoid
Post.
Med.
Lat.
Ant.
Deltoid
Pectoralis major
Capsule of
acromioclavicular
joint
Pectoralis major
Deltoid
Articular
surface for
acromion
Post.
Med.
Lat.
Trapezius
Ant.
Subclavius
Trapezoid
part
Capsule of
sternoclavicular
joint
Conoid
part
Costoclavicular
ligament
Articular
facet for
manubrium
Coracoclavicular
ligament
Fig. 2.3 Right clavicle showing attachments of the muscles and ligaments: A, superior surface; B, inferior surface.
Shaft
The shaft of the clavicle is divided into two parts: lateral onethird and medial two-third. The medial two-third of shaft is
convex forward and lateral one-third is concave forward.
Lateral One-third
It is flattened from above downwards. It has two surfaces, i.e.,
superior and inferior, and two borders, i.e., anterior and
posterior.
Surfaces
Superior surface: It is subcutaneous between the attachments
of deltoid and trapezius.
Inferior surface: It presents a conoid tubercle and
trapezoid ridge, which provide attachments to conoid and
trapezoid parts of coracoclavicular ligament, respectively.
The conoid tubercle is located on the inferior surface near
the posterior border at the junction of the lateral one-fourth
and medial three-fourth of the clavicle. The trapezoid ridge
extends forwards and laterally from conoid tubercle.
Borders
Anterior border: It is concave forwards and gives origin to
deltoid muscle. A small tubercle called deltoid tubercle may
be present on this border.
Posterior border: It is convex backwards and provides
insertion to the trapezius muscle.
Medial Two-third
It is cylindrical in shape and presents four surfaces: anterior,
posterior, superior, and inferior.
Anterior surface: It is convex forwards and gives origin to

clavicular head of pectoralis major.
Posterior surface: It is concave backwards and gives origin
to sternohyoid muscle near its medial end. The lateral part of
this surface forms the anterior boundary of cervico-axillary
canal and is related to the following structures:
1. Trunks of brachial plexus.
2. Third part of subclavian artery.
Superior surface: The clavicular head of sternocleidomastoid muscle originates from medial half of this surface.
Inferior surface: It presents the following features:
1. Costoclavicular ligament is attached to an oval
impression at its medial end.
2. Subclavius muscle is inserted into the subclavian groove
on this surface.
3. Clavipectoral fascia is attached to the margins of
subclavian groove.
4. Nutrient foramen of clavicle is located on the lateral end
of the subclavian groove.
The muscles and ligaments attached to the clavicle are
given in Table 2.1.
Table 2.1 Muscles and ligaments attached to the clavicle
Muscles
Pectoralis major
Sternocleidomastoid (clavicular head)
Deltoid
Trapezius
Subclavius
Ligaments
Coracoclavicular
Costoclavicular
Interclavicular
Table 2.2 Ossification centers of the clavicle
Fracture of clavicle (Fig. 2.4): The clavicle is the most
commonly fractured bone in the body. It commonly fractures
at the junction of its lateral one-third and medial two-third
due to blows to the shoulder or indirect forces, usually as a
result of strong impact on the hand or shoulder, when
person falls on the outstretched hand or the shoulder. When
fracture occurs, the lateral fragment is displaced downward
by the weight of the upper limb because trapezius alone is
unable to support the weight of the upper limb. In addition,
the lateral fragment is drawn medially by shoulder adductors
viz. teres major, etc. The medial fragment is slightly elevated
by the sternocleidomastoid muscle. The characteristic
clinical picture of the patient with fractured clavicle is that of
a man/woman supporting his sagging upper limb with the
opposite hand. The fracture at the junction of lateral onethird and medial two-third occurs because:
(a) This is the weakest site.
(b) Two curvatures of clavicle meet at this site.
(c) The transmission of forces (due to impact) from the
clavicle to scapula occur at this site through
coracoclavicular ligament.
N.B.
The clavicle is absent in animals in which the upper limbs
are used only for walking and weight transmission, and
not for grasping such as horse, etc.
One of the two primary centers of clavicle is regarded as
precoracoid element of reptilian shoulder girdle.
Sternocleidomastoid
Site of appearance
Time of appearance
Time of fusion
Two primary centres

(medial and lateral) in
the shaft
56 weeks of
intrauterine life
(IUL)
45th day of
IUL
Secondary centre at
sternal end
1920 years (2 years

earlier in female)
25th year
Secondary centre at the 20th year

acromial end
(occasional)
Fuses
immediately
OSSIFICATION (Fig. 2.5)

The ossification of clavicle is membranocartilaginous.
Whole of it ossifies in the membrane except its medial end
which ossifies in the cartilage. The clavicle begins to ossify
before any other bone in the body. It ossifies by four
ossification centres two primary centres for shaft and two
secondary centres, one for each end.
The site of appearance, time of appearance, and time of
fusion of various centres is given in the Table 2.2.
N.B. Growing end of clavicle: The sternal end of clavicle is
its growing end, because epiphysis at this end appears at
the age of 1920 years and unites with the shaft at the age
of 25 years. It is the last of all the epiphyses in the body to
fuse with the shaft. The radiological appearance of this
epiphysis in females confirms their bone age for legal
consent to marriage.
A
B
Congenital anomalies:
Clavicular dysostosis: It is a clinical condition in which
medial and lateral parts of clavicle remain separate due to
nonunion of two primary centers of ossification.
Cleidocranial dysostosis: It is a clinical condition
characterized by partial or complete absence of clavicle
associated with defective ossification of the skull bones.
Muscle spasm
(Teres major and
Pectoralis major)
Fig. 2.4 Clavicle fracture: A, medial fragment; B, lateral

fragment. (Source: Fig. 2.1, Page 51, Clinical and Surgical
Anatomy, 2e, Vishram Singh. Copyright Elsevier 2007, All
rights reserved.)
Acromial
end
Secondary centre
at the acromial end
(occasional)
Sternal
end
Two primary
centres
Fig. 2.5 Ossification of the clavicle.
Secondary centre
at the sternal end
13
14
Coracoid process
Spinous process
Suprascapular
notch
Acromion process
Superior angle
Glenoid cavity
(lateral angle)
Supraglenoid tubercle
Oblique ridges for

attachment of
small intramuscular
tendons of subscapularis
Infraglenoid tubercle
Medial border
Lateral border
Superior border
Inferior angle
Facet for acromioclavicular joint
Suprascapular notch
Acromion process
Spine/spinous process
Supraspinous fossa
Upper lip of spine
Lower lip of spine
Later border of acromion
Spinoglenoid notch
Suprascapular nerve
Infraspinous fossa
Lateral border
Medial border
Fig. 2.6 Right scapula: A, anterior aspect; B, posterior aspect.
SCAPULA
The scapula (shoulder blade) is a large, flattened, and
triangular bone located on the upper part of the posterolateral
aspect of the thorax, against 2nd to 7th ribs.
PARTS (Fig. 2.6)

The scapula is highly mobile and consists of four parts: a
body and three processesspinous, acromion, and coracoid.
N.B. Some authorities divide scapula into three parts, viz.
head, neck, and body.
Body
The body is triangular, thin, and transparent. It presents the
following features:
1. Two surfaces: (a) costal and (b) dorsal.
2. Three borders: (a) superior, (b) lateral, and (c) medial.
3. Three angles: (a) inferior, (b) superior, and (c) lateral.
The dorsal surface presents a shelf-like projection on its
upper part called spinous process.
The lateral angle is truncated to form an articular
surfacethe glenoid cavity.
The lateral angle is thickened and called head of the
scapula, which is connected to the plate-like body by an
inconspicuous neck.
Processes
There are three processes. These are as follows:
1. Spinous process.
2. Acromion process.
3. Coracoid process.
The spinous process is a shelf-like bony projection on the
dorsal aspect of the body.
The acromion process projects forwards almost at right
angle from the lateral end of the spine.
The coracoid process is like a birds beak. It arises from
the upper border of the head and bends sharply to project
superoanteriorly.

The side of the scapula can be determined by holding the
scapula in such a way that:
1. The glenoid cavity faces laterally, forwards, and slightly
upwards (at an angle of 45 from the coronal plane).
2. The coracoid process is directed forwards.
3. The shelf-like spinous process is directed posteriorly.

Surfaces
Costal surface (subscapular fossa)
1. It is concave and directed medially and forwards.
2. It presents three longitudinal ridges, which
provide attachment to the intramuscular tendons of
subscapularis muscle.
3. The subscapularis muscle (a multipennate muscle)
arises from the medial two-third of subscapular fossa/
costal surface except near the neck where a subscapular
bursa intervenes between the neck and the subscapular
tendon.
4. The serratus anterior muscle is inserted on this surface
along the medial border and inferior angle.
Dorsal surface
1. The dorsal surface is convex and presents a shelf-like
projection called spinous process.
2. The spinous process divides the dorsal surface into
supraspinous and infraspinous fossae. The upper,
supraspinous fossa is smaller (one-third) and lower,
infraspinous fossa is larger (two-third).
3. The spinoglenoid notch lies between lateral border of
the spinous process and the dorsal surface of the neck of
scapula. Through this notch supraspinous fossa
communicates with the infraspinous fossa and
suprascapular nerve and vessels pass from supraspinous
fossa to the infraspinous fossa.
4. The supraspinatus muscle arises from medial two-third
of supraspinous fossa.
5. The infraspinatus muscle arises from medial two-third
of infraspinous fossa.
6. The teres minor muscle arises from the upper two-third
of the dorsal surface of lateral border. This origin is
interrupted by the circumflex scapular artery.
7. The teres major muscle arises from the lower one-third
of the dorsal surface of lateral border and inferior angle
of scapula.
8. The latissimus dorsi muscle also arises from dorsal
surface of the inferior angle by a small slip.
Borders
Superior border
1. The superior border is the shortest border and extends
between superior and lateral angles.
2. The suprascapular notch is present on this border near
the root of coracoid process.
3. The suprascapular notch is converted into suprascapular
foramen by superior transverse (suprascapular) ligament.
15
16
Pectoralis minor
Coracoacromial
ligament
Short head of
biceps brachii and
coracobrachialis
Suprascapular ligament
Superior angle
Capsule of
shoulder joint
Inferior belly of omohyoid
Glenoid cavity
(lateral angle)
Long head of triceps
Serratus anterior
Subscapularis
Inferior angle
Coracoacromial ligament
Trapezius
Suprascapular ligament
Deltoid
Superior angle
Glenoid cavity
(lateral angle)
Levator scapulae
Capsule of shoulder joint
Supraspinatus

Rhomboideus minor
Circumflex scapular artery
Infraspinatus
Teres minor
Rhomboideus major
Teres major
Latissimus dorsi
Inferior angle
Fig. 2.7 Right scapula showing attachments of the muscles and ligaments: A, costal surface; B, dorsal surface.
4. The suprascapular artery passes above the ligament and

suprascapular nerve passes below the ligament, through
suprascapular foramen. (Mnemonic: Air force flies above
the Navy, i.e., A: artery is above and N: nerve is below the
ligament.)
5. The inferior belly of omohyoid arises from the superior
border near the suprascapular notch.
Lateral border
1. The lateral border is the thickest border and extends
from inferior angle to the glenoid cavity.
2. The infraglenoid tubercle is present at its upper end,
just below the glenoid cavity.
3. The long head of triceps muscle arises from the infraglenoid tubercle.
N.B. Lateral border of scapula is thick because it acts as
fulcrum during rotation of the scapula.
Medial border (vertebral border)

1. It extends from superior angle to the inferior angle.
2. It is thin and angled at the root of spine of scapula.
3. The serratus anterior muscle is inserted on the costal
surface of the medial border and the inferior angle.
4. The levator scapulae muscle is inserted on the dorsal
aspect of the medial border from superior angle to the
root of spine.
5. The rhomboideus minor muscle is inserted on the
dorsal aspect of the medial border opposite the root of
spine.
6. The rhomboideus major muscle is inserted on the dorsal
aspect of the medial border from the root of spine to the
inferior angle.
Angles
Inferior angle: It lies over the 7th rib or the 7th intercostal
space.
Superior angle: It is at the junction of superior and medial
borders, and lies over the 2nd rib.
Lateral angle (head of scapula)
1. It is truncated and bears a pear-shaped articular cavity
called the glenoid cavity, which articulates with the head
of humerus to form glenohumeral (shoulder) joint.
2. A fibrocartilaginous rim, the glenoid labrum is attached
to the margins of glenoid cavity to deepen its concavity.
3. The capsule of shoulder joint is attached to the margins
of glenoid cavity, proximal to the attachment of glenoid
labrum.
4. The long head of biceps brachii arises from supraglenoid
tubercle. This origin is intracapsular.
Processes
Spinous process (spine of scapula)
1. It is a triangular shelf-like bony projection, attached to
the dorsal surface of scapula at the junction of its upper
one-third and lower two-third.
2. It divides the dorsal surface of scapula into two parts
upper supraspinous fossa and lower infraspinous fossa.
3. The spine has two surfaces(a) superior and (b) inferior,
and three borders(a) anterior, (b) posterior, and
(c) lateral.
Surfaces
(a) The superior surface of spine forms the lower boundary
of supraspinous fossa and gives origin to supraspinatus.
(b) The inferior surface of spine forms the upper limit of
infraspinous fossa and gives origin to infraspinatus.
Borders
(a) The anterior border of spine is attached to the dorsal
surface of scapula.
(b) The lateral border of spine bounds the spinoglenoid
notch through which pass suprascapular nerve and
vessels from supraspinous fossa to infraspinous fossa.
(c) The posterior border of spine is also called crest of spine.
Trapezius is inserted to the upper lip of crest of spine,
while posterior fibres of deltoid take origin from its
lower lip.
Acromion process (acromion)
1. It projects forwards almost at right angle from the lateral
end of spine and overhangs the glenoid cavity.
2. Its superior surface is subcutaneous.
3. It has a tip, two borders (medial and lateral), and two
surfaces (superior and inferior).
4. The medial and lateral borders of acromion continue
with the upper and lower lips of the crest of the spine of
scapula, respectively.
5. Its superior surface is rough and subcutaneous.
6. Its inferior surface is smooth and related to subacromial
bursa.
7. The medial border of acromion provides insertion to
the trapezius muscle. Near the tip, medial border
presents a circular facet, which articulates with the
lateral end of clavicle to form the acromioclavicular
joint.
8. The lateral border of acromion gives origin to
intermediate fibres of the deltoid muscle.
9. The coracoacromial ligament is attached to the tip of
acromion.
10. The acromial angle is at the junction of lateral border of
acromion and lateral border of the crest of the spine of
scapula.
17
18
Coracoid process
1. It arises from the upper part of the head of scapula and
bent sharply so as to project forwards and slightly
laterally.
2. The coracoid process provides attachment to three
musclesshort head of biceps brachii, coracobrachialis,
and pectoralis minor, and three ligaments
coracoacromial, coracoclavicular, and coracohumeral.
3. The short head of biceps brachii and coracobrachialis arise
from its tip by a common tendon.
4. The pectoralis minor muscle is inserted on the medial
border of the upper surface.
5. The coracoacromial ligament is attached to its lateral
border.
6. The conoid part of the coracoclavicular ligament
(rhomboid ligament) is attached to its knuckle.
7. The trapezoid part of the coracoclavicular ligament
(rhomboid ligament) is attached to a ridge on its
superior aspect between the pectoralis minor muscle
and coracoacromial ligament.
8. The coracohumeral ligament is attached to its root
adjacent to the glenoid cavity.
N.B.
In living individual, the tip of coracoid process can be
palpated 2.5cm below the junction of lateral one-fourth
and medial three-fourth of the clavicle.
In reptiles, coracoid process is a separate bone, but in
humans it is attached to scapula and thus it represents
atavistic epiphysis.
OSSIFICATION
The ossification of scapula is cartilaginous. The cartilaginous
scapula is ossified by eight centresone primary and seven
secondary.
The primary centre appears in the body.
The secondary centres appear as follows:
1. Two centres appear in the coracoid process.
2. Two centres appear in the acromion process.
3. One centre appears each in the (a) medial border,
(b) inferior angle, and (c) in the lower part of the rim of
glenoid cavity.
The primary centre in the body and first secondary centre
in the coracoid process appears in eighth week of
intrauterine life (IUL) and first year of postnatal life,
respectively and they fuse at the age of 15 years.
All other secondary centres appear at about puberty and
fuse by 20th year.
N.B. First coracoid centre represents precoracoid element
and second coracoid (subcoracoid) centre represents
coracoid proper of reptilian girdle.
Sprengels deformity of the scapula (congenital high
scapula): The scapula develops in the neck region during
intrauterine life and then migrates downwards to its adult
position (i.e., upper part of the back of the chest). Failure
of descent leads to Sprengels deformity of the scapula. In
this condition the scapula is hypoplastic and situated in the
neck region. It may be connected to the cervical part of
vertebral column by a fibrous, cartilaginous, or bony bar
called omovertebral body. An attempt to bring down
scapula by a surgical procedure may cause injury to the
brachial plexus.
HUMERUS
The humerus is the bone of arm. It is the longest and
strongest bone of the upper limb.
PARTS (Fig. 2.8)

The humerus is a long bone and consists of three parts:
upper end, lower end, and shaft.
Upper End
The upper end presents the following five features:
1. Head.
2. Neck.
3. Greater tubercle.
4. Lesser tubercle.
5. Intertubercular sulcus.
The head is smooth and rounded, and forms less than half
of a sphere. It is directed medially backwards and upwards. It
articulates with the glenoid cavity of scapula to form the
glenohumeral (shoulder) joint.
Lower End
The lower end presents the following seven features:
1. Capitulum, a lateral rounded convex projection.
2. Trochlea, a medial pulley-shaped structure.
3. Radial fossa, a small fossa above the capitulum.
4. Coronoid fossa, a small fossa above the trochlea.
5. Medial epicondyle, a prominent projection on the
medial side.
6. Lateral epicondyle, a prominent projection on the
lateral side but less than the medial epicondyle.
7. Olecranon fossa, a large, deep hollow on the posterior
aspect above the trochlea.
Shaft
The shaft is a long part of bone extending between its upper
and lower ends. It is cylindrical in the upper half and
flattened anteroposteriorly in the lower half.
Anatomical neck
Anatomical neck
Impression for
supraspinatus
Greater tubercle
Head
Head
Lesser tubercle
Impression for
infraspinatus
Lateral lip
Impression for
teres minor
Surgical neck
Surgical neck
Medial lip
Bicipital groove
Spiral groove
Deltoid tuberosity
Deltoid tuberosity
Shaft of humerus
Shaft of humerus
Coronoid fossa
Lateral
supracondylar ridge
Medial
supracondylar ridge
Radial fossa
Lateral epicondyle
Olecranon fossa
Medial epicondyle
Medial epicondyle
Lateral epicondyle
Capitulum
A
Trochlea
Trochlea
Fig. 2.8 Right humerus: A, anterior view; B, posterior view.

The side of humerus can be determined by holding it
vertically in such a way that:
1. The rounded head at the upper end faces medially,
backwards and upwards.
2. The lesser tubercle, greater tubercle, and vertical groove
(intertubercular groove) at the upper end faces
anteriorly.
3. The olecranon fossa on the lower flattened end faces

posteriorly.

Upper End Head
1. It is smooth, rounded and forms one-third of a sphere.
2. It is covered by an articular hyaline cartilage, which is
thicker in the center and thinner at the periphery.
19
20
Neck
The humerus has three necks:
Surgical neck
Anatomical neck
1. It is constriction at the margins of the rounded head.
2. It provides attachment to the capsular ligament of the
shoulder joint, exceptsuperiorly where the capsule is
deficient, for the passage of tendon of long head of
biceps brachii, medially the capsule extends down from
the anatomical neck to the shaft for about 12 cm.
1. It is short constriction in the upper end of the shaft

below the greater and lesser tubercles/below the
epiphyseal line.
2. It is related to axillary nerve and posterior and anterior
circumflex humeral vessels.
3. It is the most important feature of the proximal end of
the humerus because it is weaker than the more proximal
regions of the bone, hence it is one of sites where the
Supraspinatus
Supraspinatus
Head
Head
Capsular ligament of
shoulder joint
Subscapularis
Infraspinatus
shoulder joint
Teres minor
Pectoralis major
Latissimus dorsi
Lateral head of triceps
Teres major
Spiral groove
Deltoid
Coracobrachialis
Deltoid
Medial head of
triceps
Brachialis
Brachioradialis
Extensor carpi
radialis longus
(ECRL)
Pronator teres
Common
extensor origin
Capitulum
elbow joint
elbow joint
Common
flexor origin
Trochlea
Anconeus
Fig. 2.9 Right humerus showing attachments of the muscles and ligaments: A, anterior aspect; B, posterior aspect.
humerus commonly fractures leading to damage of

associated nerves and vessels.
Morphological neck
1. It is the junction between diaphysis and epiphysis.
2. It is represented by an epiphyseal line in the adult bone.
3. It is a true junction of head with the shaft.
Greater tubercle
1. It is the most lateral part of the proximal end of humerus.
2. Its posterosuperior aspect bears three flattened facet-like
impressions: upper, middle, and lower, which provide
attachment to supraspinatus, infraspinatus, and teres
minor muscles, respectively.
Mnemonic: SIT, (supraspinatus, infraspinatus, teres minor).
Lesser tubercle
1. It is small elevation on the front of upper end of
humerus, just above the surgical neck.
2. It provides attachment to subscapularis muscle.
Intertubercular Sulcus/Bicipital Groove
1. It is a vertical groove between lesser and greater tubercles.
2. It contains (a) long head of biceps, enclosed in the
synovial sheath and (b) ascending branch of anterior
circumflex humeral artery.
3. Three muscles are attached in the region of this groove:
(a) Pectoralis major on the lateral lip of the groove.
(b) Teres major on the medial lip of the groove.
(c) Latissimus dorsi in the floor of the groove.
Mnemonic: Lady between 2 Majors. The L of lady stands for
latissimus dorsi and 2M stands for pectoralis major and
teres major.
Shaft
The upper part of the shaft is cylindrical and its lower part is
triangular in cross section. It has three borders and three
surfaces.
Borders
Anterior border: It starts from the lateral lip of the
intertubercular sulcus, and extends down to the anterior
margin of the deltoid tuberosity and become smooth and
rounded in the lower half, where it ends in the radial fossa.
Medial border
1. It extends from the medial lip of the intertubercular
sulcus down to the medial epicondyle. Its lower part is
sharp and called medial supracondylar ridge. This ridge
provides attachment to medial intermuscular septum.
2. A rough strip on the middle of this border provides
insertion to the coracobrachialis muscle.
3. A narrow area above the medial epicondyle provides
origin to the humeral head of the pronator teres.
Lateral border
1. Its upper part is indistinct while its lower part is
prominent where it forms the lateral supracondylar
ridge. Above the lateral supracondylar ridge, it is illdefined but traceable to the posterior part of the greater
tubercle.
2. About its middle, this border is crossed by the radial
groove from behind.
3. The lower part of this border, lateral supracondylar
ridge, provides attachment to the lateral intermuscular
septum.
Surfaces
Anterolateral surface
1. It lies between the anterior and lateral borders.
2. A little above the middle, this surface presents a
characteristic V-shaped tuberositythe deltoid tuberosity
which provides insertion to the deltoid muscle.
Anteromedial surface
1. It lies between the anterior and medial borders.
2. The upper part of this surface forms the floor of the
intertubercular sulcus.
3. About its middle and close to the medial border it
presents a nutrient foramen directed downwards.
Posterior surface
1. It lies between the medial and lateral borders.
2. In the upper one-third of this surface, there is an oblique
ridge directed downwards and laterally. This ridge
provides origin to the lateral head of the triceps brachii.
3. Below and medial to the ridge, is the radial/spiral groove,
which lodges radial nerve and profunda brachii vessels.
4. The entire posterior surface below the spiral groove
provides origin to the medial head of the triceps brachii.
Lower End
1. It is flattened from before backwards and expanded from
side to side.
2. The capitulum (rounded convex projection laterally)
articulates with the head of radius.
3. The trochlea (pulley-shaped projection medially)
articulates with the trochlear notch of ulna.
4. The ulnar nerve is related to the posterior surface of the
medial epicondyle.
5. The anterior surface of the medial epicondyle provides
an area for common flexor origin of the superficial
flexors of the forearm.
6. The anterolateral part of lateral epicondyle provides an
area for common extensor origin.
7. The posterior surface of lateral epicondyle gives origin
to anconeus muscle.
21
OSSIFICATION
The humerus is ossified by the following ossification centres:
1. One primary centre for shaft.
2. Three secondary centres for upper end.
3. Four secondary centres for lower end.
The site of appearance, time of appearance, and time of
fusion of these centres are given in the Table 2.3.
Lower End
The lower end is the widest part and presents five surfaces.
The lateral surface projects distally as the styloid process. The
dorsal surface presents a palpable dorsal tubercle (Listers
tubercle), which is limited medially by an oblique groove.

The side of radius can be determined by keeping the bone
The separate centre for medial epicondyle and its late union
with the shaft may be mistaken for the fracture of medial
epicondyle of humerus.
RADIUS
The radius is the lateral bone of the forearm and is
homologous to the medial bone of the leg, the tibia.
1. The narrow disc-shaped end (head) is directed upwards.

2. The sharpest border (interosseous border) of the shaft
is kept medially.
3. The styloid process at the lower end is directed laterally
and prominent tubercle (Listers tubercle) at lower end
faces dorsally.
4. The convexity of shaft faces laterally, and concave
anterior surface of shaft faces anteriorly.
PARTS (Fig. 2.13)

The radius is a long bone and consists of three parts: upper
end, shaft, and lower end.
Upper End
The upper end presents head, neck, and radial tuberosity.
The head is disc shaped and articulates above with the
capitulum of humerus. The neck is constricted part below
the head. The radial tuberosity is just below the medial part
of the neck.
Shaft
The long shaft extends between the upper and lower ends
and presents a lateral convexity. It widens rapidly towards
the distal end and is concave anteriorly in its distal part. Its
sharpest interosseous border is located on the medial side.
Upper End
Head
1. It is shaped like a disc and in living it is covered with an
articular hyaline cartilage.
2. It articulates superiorly with capitulum to form
humero-radial articulation.
3. The circumference of head is smooth and articulates
medially with the radial notch of ulna, rest of it is
encircled by the annular ligament.
Neck
1. It is the constricted part just below the head and is
embraced by the lower part of annular ligament.
2. The quadrate ligament is attached to the medial side of
the neck.
Table 2.3 Ossification centres of the humerus

Site of appearance
Time of appearance
Shaft
8th week of IUL
Upper end
Head
Greater tubercle
Lesser tubercle
1st year
3rd year
5th year
Lower end
Capitulum and lateral flange of trochlea
Medial part of trochlea
Lateral epicondyle
Medial epicondyle
2nd year
10th year
12th year
Fuse together at 7th year to form a conjoint

upper epiphysis
Fuse together at 14th year to form most

of the lower epiphysis
6th year (form small part of the lower epiphysis)
Time of fusion
Joins with shaft 20th year
Joins with shaft 1617th year
18th year
23
24
Olecranon process
Olecranon process
Trochlear
notch
Radial notch of
ulna
Coronoid
process
Subcutaneous area
Head of radius
Head of radius
Ulnar
tuberosity
Neck of radius
Neck of radius
Radial tuberosity
Posterior
oblique line
Posterior border
Anterior
oblique line
Shaft of ulna
Shaft of
ulna
Shaft of radius
Rough area for

pronator teres
Interosseous
borders
Interosseous
borders
Shaft of radius
Head of ulna
Head of
ulna
Styloid process of
radius
A
Dorsal tubercle
(Listers tubercle)
Styloid process of
ulna
Styloid process of
ulna
Ulnar notch of
radius
Fig. 2.13 Right radius and ulna: A, anterior view; B, posterior view.
Radial tuberosity
1. Biceps tendon is inserted to its rough, posterior part.
2. A small synovial bursa covers its smooth anterior part
and separates it from the biceps tendon.
Shaft
The shaft has three borders and three surfaces.
Borders
Anterior border
1. It starts below the anterolateral part of radial tuberosity
and runs downwards and laterally to the styloid process.
2. The upper part of this border is called anterior oblique
line and lower part forms the sharp lateral border of the
anterior surface.
Triceps
Flexor
digitorum
superficialis
Anconeus
Brachialis
Supinator
Biceps brachii
Pronator
teres
Flexor
pollicis
longus
Supinator
Flexor digitorum
superficialis
Biceps brachii
Common
aponeurosis of
FCU, ECU, and FDP
Supinator
Abductor pollicis
longus
Flexor
digitorum
profundus
Flexor
digitorum
profundus
Extensor
pollicis longus
Pronator teres
Extensor pollicis
brevis
Extensor indicis
Flexor pollicis
longus
Posterior border
Pronator
quadratus
Brachioradialis
Styloid process of
radius
Styloid process of
radius
Capsule of
wrist joint
Capsule of
wrist joint
Styloid process of
ulna
Dorsal tubercle of
radius
(Listers tubercle)
Styloid process of
radius
Fig. 2.14 Radius and ulna of right side showing attachments of the muscles and ligaments: A, anterior aspect; B, posterior
aspect (FCU = flexor carpi ulnaris, ECU = extensor carpi ulnaris, FDP = flexor digitorum profundus).
3. Its anterior oblique line gives origin to radial head of

flexor digitorum superficialis (FDS).
2. Above it runs upwards and medially to the radial

tuberosity and form the posterior oblique line.
Posterior border
Medial (interosseous) border
1. It is well-defined only in its middle third of the shaft.
1. It is the sharpest border.
25
26
2. It extends above up to radial tuberosity and below its

lower part forms the posterior margin of the small
triangular area on the medial side of the lower end of the
bone.
3. Interosseous membrane is attached to its lower threefourth.
Surfaces
Anterior surface
1. It is concave and lies between anterior and interosseous
borders.
2. Flexor pollicis longus originates from its upper
two-fourth.
3. Pronator quadratus is inserted on its lower one-fourth.
4. Nutrient foramen is present a little above the middle of
this surface in its upper part. The nutrient canal is
directed upwards. Nutrient artery for radius is a branch
from anterior interosseous artery.
Posterior surface
1. It lies between the interosseous and posterior borders.
2. Abductor pollicis longus (APL) arises from the middle
one-third of this surface.
3. Extensor pollicis brevis (EPB) arises from lower part of
this surface.
Lateral surface
1. It lies between anterior and posterior borders.
2. Supinator is inserted on the widened upper one-third of
this surface.
3. Pronator teres is inserted on the rough area in the most
convex middle part of this surface.
Lower End
The lower end is the widest part of the bone and has five
surfaces.
Anterior surface: The anterior surface presents a thick
ridge, which provides attachment to palmar radio-carpal
ligament of wrist joint.
Posterior surface: The posterior surface presents the
dorsal tubercle of Lister lateral to the groove for the tendon of
extensor pollicis longus. It also presents grooves for other
extensor tendons.
The groove lateral to the Listers tubercle is traversed by
tendons of extensor carpi radialis longus (ECRL) and extensor
carpi radialis brevis (ECRB). Through the groove medial to
groove for extensor pollicis longus passes tendons of extensor
digitorum and extensor indicis.
Medial surface: The medial surface presents the ulnar
notch for articulation with the head of ulna. Articular disc of
inferior radio-ulnar joint is attached to the lower margin of
ulnar notch.
Lateral surface: The lateral surface projects downward as
the styloid process and is related to tendons of adductor
pollicis longus and extensor pollicis brevis. The brachioradialis

is inserted to the base of styloid process and radial collateral
ligament of wrist joint is attached to the tip of styloid process.
Inferior surface: The inferior (distal) surface presents a
lateral triangular area for articulation with the scaphoid and
a medial quadrangular area for articulation with the lateral
part of the lunate.
Fracture of radius: The radius is a weight-bearing bone of
the forearm; hence fractures of radius are more common
than ulna.
(a) In fracture shaft of radius, with fracture line below the
insertion of biceps and above the insertion of pronator
teres the upper fragment is supinated by supinator and
lower fragment is pronated by the pronator teres.
(b) In fracture at the distal end of radius (Colles fracture)
the distal fragment is displaced backwards and upwards.
The reverse of Colles fracture is called Smiths fracture
(Fig. 2.15).
(c) Fracture of styloid process of radius is termed Chauffeurs
fracture.
N.B. The radius is most commonly fractured bone in people

over 50 years of age. It is often fractured as a result of a fall
on outstretched hand.
OSSIFICATION
The radius ossifies from the following three centres:
1. One primary centre appears in the mid-shaft during 8th
week of 1UL.
Distal fragment
displaced posteriorly
A
Radius
Distal fragment
displaced anteriorly
Fig. 2.15 Fracture at distal end of the radius: A, Colles

fracture; B, Smiths fracture. (Source: Fig. 2.3, Page 53,
Clinical and Surgical Anatomy, 2e, Vishram Singh. Copyright
2007, All rights reserved.)
2. Two secondary centres, one for each end:

(a) Centre for lower end appears at the age of first year.
(b) Centre for upper end appears during fifth year.
3. The upper epiphysis fuses at the age of 12 years.
4. The lower epiphysis fuses at the age of 20th year.
Madelung deformity: It is a congenital anomaly of radius
which presents the following clinical features:
The anterior bowing of distal end of radius, due to an
abnormal growth of distal epiphysis.
It occurs between 10 and 14 years of age.
There is premature disappearance of distal epiphyseal
line.
There may be subluxation or dislocation of distal end of
ulna, due to defective development of distal radial
epiphysis.
ULNA
The ulna is the medial bone of forearm and is homologous
to the lateral bone of legthe fibula.
PARTS (Fig. 2.13)

The ulna is a long bone and consists of three parts: upper
end, lower end, and shaft.
Upper End
The upper end is expanded and hook-like with concavity of
hook facing forwards. The concavity of upper end (trochlear
notch) lies between large olecranon process above and the
small coronoid process below.
Shaft
The long shaft extends between the upper and lower ends. Its
thickness diminishes progressively from above downwards
throughout its length. The lateral border (interosseous border)
is sharp crest-like.
Lower End
The lower end is slightly expanded and has a head and styloid
process. The styloid process is posteromedial to the head.
N.B. The ulna looks like a pipe wrench with olecranon
process resembling the upper jaw, the coronoid fossa, the
lower jaw, and the trochlear notch the mouth of the wrench.

The side of ulna can be determined by keeping the bone
1. The broad hook-like end is directed upwards.

2. The sharp crest-like interosseous border of shaft is
directed laterally.
3. The concavity of the hook-like upper end and the
coronoid process are facing forwards.

Upper End
The upper end has two processes: coronoid and olecranon,
and two notches: trochlear and radial.
Processes
Olecranon process: It projects upwards from the upper end
and bends forward at its summit like a beak. It has the following five surfaces:
1. Upper surface
(a) Its rough posterior two-third provides insertion to
the triceps brachii.
(b) Capsular ligament of elbow joint is attached
anteriorly near its margins.
(c) A synovial bursa lies between the tendon of triceps
and capsular ligament.
2. Anterior surface: It is smooth and forms upper part of
the trochlear notch.
3. Posterior surface
(a) It forms a subcutaneous triangular area.
(b) A synovial bursa (subcutaneous olecranon bursa)
lies between posterior surface and skin.
4. Medial surface: Its upper part provides attachments to
three structures: (a) ulnar head of flexor carpi ulnaris
(origin), (b) posterior, and (c) oblique bands of ulnar
collateral ligament.
Coronoid process: It is bracket-like projection from the front
of the upper end of the ulna below the olecranon process. It
has four surfaces: superior, anterior, medial, and lateral.
1. Superior surface: It is smooth and forms the lower part
of trochlear notch.
2. Anterior surface: It is triangular in shape.
(a) Its lower corner presents an ulnar tuberosity.
(b) Brachialis muscle is inserted to the whole of the
anterior surface including ulnar tuberosity.
(c) The medial margin of the anterior surface is sharp
and has a tubercle at its upper end called sublime
tubercle. The medial margin provides attachment to
the following structures from proximal to distal:
(i) Anterior band of ulnar collateral ligament.
(ii) Oblique band of ulnar collateral ligament.
(iii) Humero-ulnar head of flexor digitorum
superficialis.
27
28
(iv) Ulnar head of pronator teres.

(v) Ulnar head of flexor pollicis longus.
3. Medial surface: It gives origin to flexor digitorum
profundus.
4. Lateral surface: The upper part of this surface possesses
a radial notch for articulation with the head of the
radius.
(a) The annular ligament is attached to the anterior
and posterior margins of the radial notch.
(b) The lower part of the lateral surface below radial
notch has a depressed area called supinator fossa,
which accommodates radial tuberosity during
supination and pronation.
(c) Supinator fossa is bounded behind by supinator
crest. Supinator crest and adjoining part of
supinator fossa gives origin to the supinator muscle.
Notches (articular surfaces)
Trochlear notch
1. It is C-shaped (semilunar) and articulates with the
trochlea of humerus.
2. It has a non-articular strip at the junction of its
olecranon and coronoid parts.
3. Its superior, medial, and anterior margins provide
attachment to capsule of the elbow joint.
Radial notch
It articulates with the head of radius to form the superior
radio-ulnar joint.
Shaft
It has three borderslateral, anterior, and posterior; and
three surfacesanterior, medial, and posterior.
Borders
Lateral (interosseous) border
1. It is sharpest and is continuous above with the supinator
crest.
2. It is ill-defined below.
3. Interosseous membrane is attached to this border except
for its upper part.
2. It is subcutaneous throughout, hence can be palpated

along its entire length.
3. It provides attachment to three muscles by a common
aponeurosis. The muscles are:
(a) Flexor digitorum profundus.
(b) Flexor carpi ulnaris.
(c) Extensor carpi ulnaris.
Surfaces
Anterior surface
1. It lies between anterior and interosseous borders.
2. The flexor digitorum profundus arises from its upper
three-fourth.
3. The pronator quadratus arises from an oblique ridge on
the lower one-fourth of this surface.
4. The nutrient foramen is located a little above the middle
of this surface and is directed upwards.
Medial surface
1. It lies between the anterior and posterior borders.
2. The flexor digitorum profundus arises from the upper
two-third of this surface.
Posterior surface
1. It lies between posterior and interosseous borders.
2. It is divided into smaller upper part and large lower part
by an oblique line, which starts at the junction of upper
and middle third of posterior border and runs towards
the posterior edge of radial notch.
3. Area above the oblique line receives insertion of anconeus
muscle.
4. Area below the oblique line is divided into larger medial
and smaller lateral parts by a faint vertical line. The
lateral part provides attachment to three muscles form
proximal to distal as follows:
(a) Abductor pollicis longus in the upper one-fourth.
(b) Extensor pollicis longus in the middle one-fourth.
(c) Extensor indicis in the next one-fourth.
(d) The distal one-fourth is devoid of any attachments.
Lower End
The lower end consists of head and styloid process.
Anterior border
1. It extends from the medial side of the ulnar tuberosity to
the base of styloid process.
2. It is thick and round.
3. It upper three-fourth gives origin to flexor digitorum
profundus.
Posterior border
1. It starts from the apex of triangular subcutaneous area
on the back of olecranon process and descends to the
styloid process.
Head
1. It presents a convex articular surface on its lateral side
for articulation with the ulnar notch of radius to form
the inferior radio-ulnar joint.
2. Its inferior surface is smooth and separated from wrist
joint by an articular disc of inferior radio-ulnar joint.
Styloid process
1. It projects downwards from the posteromedial aspect of
the head of ulna.
2. Its tip provides attachment to medial collateral ligament

of wrist joint.
3. The apex of triangular articular disc is attached to the
depression between head and base of styloid process.
4. Tendon of extensor carpi ulnaris lies in the groove
between the back of the head of ulna and styloid process.
N.B. The styloid process is subcutaneous, and may be felt
in living individual slightly distal to the head when the
forearm is pronated.
When the elbow is fully extended, the tip of olecranon
process and medial and lateral epicondyles of the
humerus lie in a same horizontal line. When the elbow is
fully flexed the three bony points form an equilateral
triangle. In dislocation of elbow this relationship is
disturbed.
Ulna stabilizes the forearm by gripping the lower end of
humerus by its trochlear notch and provides foundation
for radius to produce supination and pronation at superior
and inferior radio-ulnar joints.
The fracture of upper third of shaft of ulna with dislocation
of radial head at superior radio-ulnar joint is called
Monteggia fracture dislocations.
The fracture of lower third of the shaft of radius associated
with dislocation of inferior radio-ulnar joint is called
Galeazzi fracture dislocation.
A fracture of the shaft of ulna due to direct injury when a
night watchman reflexly raises his forearm to ward off the
blow of the stick is termed night-stick fracture.
OSSIFICATION
The ulna ossifies from the three main centres: one primary
centre for the shaft and two secondary centres, one each for
the lower end and the upper end.
Primary centre
It appears in the mid-shaft during eighth week of IUL.
Secondary centres
Upper end
Appearance: 9 years (upper part of trochlear surface and top
of olecranon process).
Fusion:
18 years.
CARPAL BONES (Fig. 2.16)

The carpus (G. Corpus = wrist) consists of eight carpal
bones, which are arranged in two rows: proximal and distal.
Each row consists of four bones.
The proximal row of carpal bones consists of the following
bones from lateral to medial side:
1.
2.
3.
4.
Scaphoid.
Lunate.
Triquetral.
Pisiform.
The distal row of carpal bones consists of the following

bones from lateral to medial side:
1.
2.
3.
4.
Trapezium.
Trapezoid.
Capitate.
Hamate.
Mnemonic: She Looks Too Pretty. Try To Catch Her.
IDENTIFICATION OF INDIVIDUAL CARPAL BONES

The individual carpal bones can be identified by looking at
their shape and few other features. These are given in the
Table 2.4.
N.B. Morphology: Carpus of primitive tetrapods consists of
three bones in the proximal row, five bones in the distal row
and an Os centrale between the two rows.
The pisiform bone is usually regarded as a sesamoid
bone developed in the tendon of flexor carpi ulnaris, but
some authorities regard it as a displaced Os centrale.
Scaphoid fracture (Fig. 2.17): Fracture of scaphoid is the
most common fracture of carpus and usually occurs due to
fall on the outstretched hand. Fracture occurs at the narrow
waist of the scaphoid. Clinically it presents as tenderness
in the anatomical box. Blood vessels mostly enter the
scaphoid through its both ends. But in 1015% cases, all
the blood vessels supplying proximal segment enter it
through its distal pole. In this condition when waist of
scaphoid is fractured, the proximal segment is deprived of
blood supply and may undergo avascular necrosis.
Lower end (middle of head)

Appearance: 6 years.
Fusion:
20 years.
N.B. Distal part of olecranon process is formed as an
upward extension of the shaft.
OSSIFICATION
The carpal bones are cartilaginous at birth. Each carpal
bone ossifies by one centre and all these centres appear
after birth.
29
30
Radius
Ulna
Ulna
Radius
Lunate
Triquetral
Scaphoid
Carpal
bones
Pisiform
Trapezium
Capitate
Trapezoid
Metacarpals
Hamate
First
metacarpal
Metacarpals
Proximal phalanx
Phalanges
Phalanges
Middle phalanx
Distal phalanx
A
Fig. 2.16 Bones of the hand: A, schematic diagram; B, as seen in radiographs. (Source: Fig. 7.91B, Page 710, Gray's
Anatomy for Students, Richard L Drake, Wayne Vogl, Adam WM Mitchell. Copyright Elsevier Inc. 2005, All rights reserved.)
Table 2.4 Identification of the carpal bones
Carpal bone
1. Scaphoid
2. Lunate
3. Triquetral
4. Pisiform
5. Trapezium
6. Trapezoid
7. Capitate
8. Hamate
Identifying features
Boat-shaped
Has constriction (neck)
Has tubercle on distal part of its palmar
surface
Moon-shaped/crescentic
Pyramidal in shape
Oval facet on the distal part of its palmar
surface for articulation with pisiform
Pea-shaped/pea-like
Oval facet on the proximal part of its dorsal
surface
Quadrilateral in shape
Has groove and crest (tubercle) on its
palmar surface
Shoe-shaped
Largest carpal bone
Has rounded head on its proximal surface
Wedge-shaped
Hook-like process projects from distal part
of its palmar surface
The centres appear as follows:

Capitate
Second month
Hamate
End of third month
Triquetral Third year
Lunate
Scaphoid
Fourth year, in females and fifth year in males
Trapezium
Trapezoid
Pisiform Twelfth year in males, 9th to 10th year in females
N.B. The capitate is the first bone to ossify and pisiform is
the last bone to ossify.
The spiral sequence of ossification of the carpal bones

and approximate ages in years is given in Figure 2.18.
The knowledge of ossification of carpal bones is important
in determining the bone age of the child.
METACARPAL BONES
The metacarpus consists of five metacarpal bones. They are
conventionally numbered one to five from lateral (radial) to
medial (ulnar) side.
Trapezoid
Trapezium
PARTS
Scaphoid
fracture
Each metacarpal is a small long bone and consists of three

parts: (a) head, (b) shaft, and (c) base.
Capitate
Head
The head is at distal end and rounded.
Lunate
Shaft
The shaft extends between head and base. It is concave on
palmar aspect and on sides. The dorsal surface of shaft
presents a triangular area in its distal part.
Hamate
Capitate
Trapezium
PECULIARITIES OF FIRST METACARPAL
Triquetral
Scaphoid
fracture
Lunate
Base
The base is proximal end and expanded.
Ulna
Radius
Fig. 2.17 Fracture of scaphoid bone (arrow): A, in radiograph

of the hand (AP view); B, CT scan of the wrist. (Source: Fig.
5.6, Page 131, Integrated Anatomy, David JA Heylings, Roy
AJ Spence, Barry E Kelly. Copyright Elsevier Limited 2007,
All rights reserved.)
1. The first metacarpal is the shortest and stoutest bone.

2. It is rotated medially through 90 so that its dorsal
surface faces laterally.
3. Its base possesses concavo-convex (saddle-shaped)
articular surface for articulation with trapezium.
4. The head is less convex and broader than other metacarpals.
5. The sesamoid bones glide on radial and ulnar corners of
head and produces impressions of gliding.
6. Its base dose not articulate with any other metacarpal.
7. It has epiphysis at its proximal end unlike other
metacarpals, which have epiphysis at their distal end.
OSSIFICATION
4th to 5th year
Each metacarpal ossifies by two centres: one primary centre

for the shaft and the one secondary centre for the head.
Sca
Tri (3rd year)
Lun
Pisiform
Cap
Tr
Ham
Tz
3rd month
2nd month
Fig. 2.18 Ossification of the carpal bones (Scap = scaphoid,

Lun = lunate, Tri = triquetral, Tr = trapezium, Tz = trapezoid,
Cap = capitate, Ham = hamate).
N.B. The secondary centre of first metacarpal appears in its

base.
The time of appearance of centres and their fusion is

given in the box below:
Center
Primary centre for shaft
Secondary centre for head of
second, third, fourth, and fifth
metacarpal
Secondary centre for base for
first metacarpal
Time of appearance Fusion

9th week of IUL
2 years
16 years
2 years
18 years
31
32
Shaft
1. The shaft tapers towards the head.
2. The dorsal surface is convex from side to side.
3. The palmar surface is flat from side to side but gently
concave in the long axis.
Head
1. The heads of proximal and middle phalanges are pulley
shaped.
2. The heads of distal phalanges is non-articular and has
rough horseshoe-shaped tuberosity.
OSSIFICATION
Fig. 2.19 An X-ray of hand showing boxers fractureneck
of 5th metacarpal (arrow). (Source: Fig. 5.8, Page 131,
Integrated Anatomy, David JA Heylings, Roy AJ Spence,
Barry E Kelly. Copyright Elsevier Limited 2007, All rights
reserved.)
Bennets fracture: It is an oblique fracture of the base of
1st metacarpal. It is intra-articular and may be associated
with subluxation or dislocation of metacarpal.
Boxers fracture (Fig. 2.19): It is fracture of neck of
metacarpal, and most commonly involves neck of 5th
metacarpal.
PHALANGES
There are 14 phalanges in each hand: two in thumb and three
in each finger.
PARTS AND FEATURES

Each phalanx is a short long bone and has three parts:
(a) base (proximal end), (b) head (distal end), and (c) shaft
(extending between the two ends).
Base
1. The bases of proximal phalanges have concave oval facet
for articulation with the heads of metacarpals.
2. The bases of middle and distal phalanges possess pulleyshaped articular surfaces.
Each phalanx ossifies by the two centres: one primary centre

for the shaft and one secondary centre for the base.
Their time of appearance is as follows:
Primary centres
For proximal phalanx: 10th week of IUL.
For middle phalanx: 12th week of IUL.
For distal phalanx: 8th week of IUL.
Secondary centres
Appearance: 2 years.
Fusion: 16 years.
An undisplaced fracture of phalanx can be treated
satisfactorily by strapping the fractured finger with the
neighboring finger.
N.B. The sesamoid bones in region of hand are found on

the following sites:
(a) Sesamoid bone in the tendon of flexor carpi ulnaris
(pisiform).
(b) Two sesamoid bones on the palmar surface of the head
of first metacarpal.
(c) Sesamoid bone in the capsule of interphalangeal (IP)
joint of thumb (in 75% cases).
(d) Sesamoid bone on the ulnar side of capsule of MCP
joint of little finger (in 75% cases).
The sesamoid bones related to head of the first
metacarpal bones are generally noticed in X-ray of hand
(Fig. 2.15).
CHAPTER
Pectoral Region
The pectoral region is the anterior aspect of the thorax

(chest). The important structures are present in this region
are:
1. Muscles that connect the upper limb with the
anterolateral chest wall.
2. Breasts (mammary glands) which secrete milk (in female).
SURFACE LANDMARKS
The following landmarks can be felt on the surface of the
body in this region (Fig. 3.1):
1. Clavicle: Being subcutaneous in location, it is palpable
along its whole length at the junction of root of the neck
and front of the chest.
2. Suprasternal notch (jugular notch): It is a palpable
notch at the upper border of manubrium sterni between
the medial ends of two clavicles.
3. Sternal angle (angle of Louis): It is felt as a transverse
ridge about 5 cm below the suprasternal notch. It marks
the junction of manubrium and the body of the sternum.
On either side, the costal cartilage of 2nd rib articulates
with the sternum at this level. The sternal angle thus
serves as a useful landmark to identify the 2nd rib and
subsequently helps in counting down the other ribs.
4. Infraclavicular fossa: It is a triangular depression below
the junction of middle and lateral third of the clavicle.
5. Coracoid process: The tip of coracoid process is felt in
the infraclavicular fossa, 2.5 cm below the clavicle.
6. Nipple: It is the most important surface feature of the
pectoral region. Its position varies considerably in the
female but in the male, it usually lies in the 4th intercostal
space just medial to the midclavicular line.
Infraclavicular fossa
Coracoid
process
Clavicle
Suprasternal
notch
Manubrium
Acromion
Sternal angle
Greater
tubercle of
humerus
Second
costal
cartilage
Lesser
tubercle of
humerus
Body of
sternum
Xiphoid
process
Nipple
Fig. 3.1 Skeletal framework and surface landmarks of the

pectoral region.
1. Midsternal line: It runs vertically downwards in the

median plane on the front of the sternum.
2. Midclavicular line: It runs vertically downwards from
the midpoint of the clavicle to the midinguinal point.
3. Anterior axillary line: It runs vertically downwards from
the anterior axillary fold.
4. Midaxillary line: It runs vertically downwards from a
point located midway between the anterior and posterior
axillary folds.
5. Posterior axillary line: It runs vertically downwards
from the posterior axillary fold.
LINES OF ORIENTATION
CUTANEOUS INNERVATION
The following lines are often used to describe the surface

features on the anterior chest wall:
The skin of the pectoral region is supplied by the following

cutaneous nerves (Fig. 3.2):
Pectoral Region
MUSCLES
The muscles of the pectoral region are:
Supraclavicular
nerves
Clavicle
Sternal
angle
Intercostobrachial
nerve
Anterior
cutaneous
nerves (T2T6)
1.
2.
3.
4.
Pectoralis major.
Pectoralis minor.
Subclavius.
Serratus anterior.*
PECTORALIS MAJOR (Figs 3.4 and 3.5)

It is the largest muscle of the pectoral region.
Lateral cutaneous
nerves (T3T6)
Origin
Pectoralis major muscle is thin fan shaped and arises by two
heads, viz.
Fig. 3.2 Cutaneous nerves of the pectoral region.
1. The skin above the horizontal line drawn at the level of

sternal angle is supplied by supraclavicular nerves (C3
and C4).
2. The skin below this horizontal line is supplied by
anterior and lateral cutaneous branches of the 2nd6th
intercostal nerves (T2T6).
N.B. The area supplied by C4 spinal segment directly meets
the area supplied by T2 spinal segment. This is because the
nerves derived from C5T1 spinal segments form brachial
plexus to supply the upper limb (Fig. 3.3).
1. Small clavicular head.

2. Large sternocostal head.
Clavicular headarises from the medial half of the anterior
aspect of the clavicle.
Sternocostal headarises from the (a) lateral half of
the anterior surface of the sternum, up to 6th costal
cartilage, (b) medial parts of 2nd6th costal cartilages,
and (c) aponeurosis of the external oblique muscle of the
abdomen.
Insertion of
pectoralis
minor
Insertion of
pectoralis
major
Origin of clavicular head of

pectoralis major
Origin of
sternocostal
head of
pectoralis
major
C3
C4
T2
T3
T4
T1
Horizontal line
passing through
sternal angle
Origin of
pectoralis
minor
T5
T6
Fig. 3.4 Bony attachments of the pectoralis major and

minor muscles.
Costal margin
*The serratus anterior is a thin muscular sheet overlying the lateral

Fig. 3.3 Dermatomes in the pectoral region.
aspect of chest wall, hence, it is not a muscle of pectoral region but

grouped with pectoral muscles for convenience of study and surgical
significance.
35
36
PECTORALIS MAJOR
Clavicular head
Sternocostal head
Origin
1. Anterior surface of
the medial half of
clavicle
2. Anterior surface of
the sternum
Clinical testing: On lifting a heavy rod, the clavicular head

becomes prominent and when one attempts to depress
the rod, the sternocostal head becomes prominent.
Congenital anomaly of pectoralis major: Occasionally,
a part of the pectoralis major, usually the sternocostal
part, is absent at birth. This causes weakness in adduction
and medial rotation of the arm.
3. Medial parts of
2nd6th
costal cartilages
PECTORALIS MINOR (Figs 3.4 and 3.6)

Insertion
Lateral lip of
intertubercular sulcus
4. Aponeurosis of
external oblique
It is the small triangular muscle that lies deep to the pectoralis

major muscle.
Origin
It arises from 3rd, 4th, and 5th ribs, near their costal
cartilages.
Fig. 3.5 Origin and insertion of the pectoralis major muscle.
Insertion
Pectoralis major is inserted by a U-shaped (bilaminar) tendon on to the lateral lip of the bicipital groove. The anterior
lamina of the tendon is formed by the clavicular fibres, while
posterior lamina is formed by sternocostal fibres. The two
laminae are continuous with each other inferiorly.
The lower sternocostal and abdominal fibres in their
course to insertion are twisted in such a way that fibres,
which are lowest are inserted highest.
This twisting of fibres forms the rounded axillary fold.
Insertion
It is inserted by a short thick tendon into the medial border
and upper surface of the coracoid process of the scapula.
Nerve Supply
Nerve supply is by medial and lateral pectoral nerves.
Nerve Supply
Nerve supply is by lateral (C5 to C7) and medial pectoral (C8
and T1) nerves.
N.B.
The pectoralis major and pectoralis minor muscles are
the only muscles of the upper limb, which are supplied
by all five spinal segments that form the brachial
plexus.
Occasionally a vertical sheet of muscle fibres extending
from root of the neck to the upper part of the abdomen
passes superficial to the medial part of pectoralis major.
It is termed rectus sternalis/sternalis muscle.
Actions
The clavicular head flexes the arm, whereas sternocostal head
adducts and medially rotates the arm.
PECTORALIS
MINOR
Insertion
Medial border and
upper surface of the
coracoid process
Origin
From 3rd, 4th, and
5th ribs near their
costal cartilages
Fig. 3.6 Origin and insertion of the pectoralis minor muscle.
38
Origin
It arises by a series of 8 digitations from upper eight ribs. The
first digitation arises from the 1st and 2nd ribs, whereas all
other digitations arise from their corresponding ribs.
Insertion
It is inserted into the costal surface of the scapula along its
medial border. (The first 2 digitations are inserted into the
superior angle, next 2 digitations into the medial border and
the lower 4 or 5 digitations into the inferior angle of the
scapula.)
Nerve Supply
It is by long thoracic nerve/nerve to serratus anterior (C5,
C6, and C7).
Actions
1. It is a powerful protractor of the scapula, i.e., it pulls the
scapula forward around the chest wall for pushing and
punching movements as required during boxing. Hence,
serratus anterior is also called boxers muscle.
2. It keeps the medial/vertebral border of scapula in firm
contact with the chest wall.
3. Its lower 4 or 5 digitations along with lower part of the
trapezius rotate the scapula laterally and upwards during
overhead abduction of the arm.
Paralysis of serratus anterior: The paralysis of serratus
anterior muscle following an injury to long thoracic nerve by
stab injury or during removal of the breast tumor leads to the
following effects:
(a) Protraction of scapula is weakened.
(b) Inferior angle and medial border of scapula become
unduly prominent particularly when patient pushes his
hands against the wall, producing a clinical condition
called winging of the scapula (Fig. 3.9).
FASCIAE
PECTORAL FASCIA
It is the deep fascia covering the anterior aspect of the
pectoralis major muscle. It is thin and anchored firmly to the
muscle by numerous fasciculi.
Extent
1. Superiorly, it is attached to the clavicle.
Fig. 3.9 The winging of right scapula. The vertebral border

and inferior angle of scapula protrude posteriorly, when the
patient is asked to press his hands against the wall.
2. Inferiorly, it is continuous with the fascia of anterior

abdominal wall.
3. Superolaterally, it passes over the deltopectoral groove
to become continuous with the fascia covering the
deltoid muscle.
4. Inferolaterally, it curves round the inferolateral border
of the pectoralis major to become continuous with the
axillary fascia. The axillary fascia is a dense fibrous sheet
that extends across the base of the axilla.
CLAVIPECTORAL FASCIA (Fig. 3.10)

The clavipectoral fascia is a strong fascial sheet deep to the
clavicular head of the pectoralis major muscle, filling the
space between the clavicle and the pectoralis minor muscle.
Extent
1. Vertically, it extends from clavicle above to the axillary
fascia below. Its upper part splits into two laminae to
enclose the subclavius muscle. The posterior lamina
becomes continuous with the investing layer of deep
cervical fascia and gets fused with the axillary sheath.
The anterior lamina gets attached to the clavicle.
Its lower part splits to enclose the pectoralis minor
muscle. Below this muscle it extends downwards as the
suspensory ligament of axilla, which is attached to the
dome of the axillary fascia. The suspensory ligament
keeps the dome of axillary fascia pulled up, thus
maintaining the concavity of the axilla.
2. Medially, clavipectoral fascia is attached to the first rib
and costoclavicular ligament and blends with external
intercostal membrane of the upper two intercostal spaces.
Pectoral Region
Structures piercing clavipectoral fascia

Investing layer of
deep cervical
fascia
1. Thoraco-acromial artery
2. Cephalic vein
3. Lateral pectoral nerve
4. Lymphatics
Clavipectoral
fascia
Axillary vein
Axillary artery
Lateral cord of
brachial plexus
Subclavius muscle
Pectoral fascia
Clavipectoral
fascia
Pectoralis minor
Pectoralis major
Anterior
axillary fold
Coracoclavicular
ligament
Fig. 3.11 Structures piercing the clavipectoral fascia.

(Source: Fig. 1.9, Page 11, Selective Anatomy Prep Manual
for Undergraduates, Vol. I, Vishram Singh. Copyright Elsevier
2014, All rights reserved.)
Axillary
fascia
Subclavius
First rib Clavicle
Costoclavicular
ligament
Coracoid process
Coracobrachialis
Short head of
biceps brachii
B
Clavipectoral
Pectoralis minor
fascia
Fig. 3.10 Clavipectoral fascia: A, as seen in sagittal section

of anterior axillary wall; B, as seen from front.
BREAST (MAMMARY GLAND)

The mammary gland is a modified sweat gland present in the
superficial fascia of the pectoral region. The mammary gland
is found in both sexes. However, it remains rudimentary in
male but becomes well-developed in female at puberty. On
rare occasions the breasts of male become enlarged, this
condition is called gynecomastia. In female, it forms an
accessory sex organ of female reproductive system and
provides milk to the newborn baby. The anatomy of breast is
of great surgical importance, and therefore, needs to be
studied in detail.
LOCATION (Figs 3.12 and 3.13)

3. Laterally, it is attached to the coracoid process and
blends with the coracoclavicular ligament. The thick
upper part of the fascia extending from first rib near
costochondral junction to the coracoid process is called
costocoracoid ligament.
N.B. The clavipectoral fascia encloses two muscles
subclavius and pectoralis minor.
The breast is located in the superficial fascia of the pectoral

region. A small extension from its superolateral part
(axillary tail of Spence) however pierces the deep fascia
and extends into the axilla. The aperture in the deep fascia
through which axillary tail passes into the axilla is called
foramen of Langer. The axillary tail is the site of high
percentage of breast tumor.
SHAPE AND EXTENT (Figs 3.12 and 3.13)

Structures Piercing the Clavipectoral Fascia
These are as follows (Fig. 3.11):
1. Lateral pectoral nerve.
2. Thoraco-acromial artery.
3. Lymphatics from the breast to the apical group of
axillary group of lymph nodes.
4. Cephalic vein. The first two structures pass outwards,
whereas the lower two structures pass inwards.
Shape
Hemispherical bulge.
Extent
1. Vertically, it extends from 2nd rib to 6th rib.
2. Horizontally, it extends from lateral border of the
sternum to the midaxillary line.
39
Pectoral Region
Clavicle
Clavicle
Pectoral fascia
Pectoral fascia
Pectoralis major
Pectoralis major
Ligaments of
Cooper
Lactiferous sinus
Fat
Lactiferous duct
Lobes of the breast
Lobes of the breast
Fig. 3.16 Structure of the breast: A, parenchyma (lobes of the breast); B, stroma of the breast (suspensory ligaments of
Cooper and fat).
Skin: It is the covering for the breast and presents the

following features:
1. Nipple: It is a conical projection below the center of the
breast, usually at the level of the 4th intercostal space. It
contains smooth muscle fibres, which can make the
nipple stiff and erect or flatten it. Being richly innervated
by sensory nerve endings, the nipple is the most sensitive
part of the breast to tactile stimulation and become erect
during sexual arousal.
2. Areola: It is the circular area of pigmented skin
surrounding the base of the nipple. It contains large
number of modified sebaceous glands, particularly at its
outer margin. They produce oily secretion, which
lubricates the nipple and areola, and thus prevents them
from drying and cracking. The color of the areola and
nipple varies with the complexion of the woman. During
pregnancy the areola becomes darker and enlarged.
N.B. The sebaceous glands in the areola are enlarged
during pregnancy and appear as small nodular elevations
called Montgomerys tubercles.
Stroma: The stroma of breast consists of connective tissue

and fat. It forms the supporting framework of the breast.
The connective tissue condenses to form fibrous strands/
septa, called suspensory ligaments of Cooper.
The suspensory ligaments of Cooper are arranged in a

radial fashion. They connect the dermis of the overlying skin
to the ducts of the breast and pectoral fascia. The ligaments
of the Cooper maintain the protuberance of the breast. Their
atrophy due to ageing makes the breast pendulous in old age.
The fat forms the most of the bulk of the breast. It is
distributed all over the breast except beneath the areola and
the nipple.
Parenchyma: The parenchyma/glandular tissue of the breast
secrete milk to feed the newborn baby. It consists of about
1520 lobes arranged in a radial fashion like the spokes of a
wheel and converge towards the nipple. Each lobe is divided
Fat
Areola
Nipple
Lactiferous
duct
Acini
Lobules
Lactiferous sinus
Fig. 3.17 Structure of the lobe of the mammary gland.
41
Pectoral Region
Supraclavicular nodes
Deltopectoral node
Axillary lymph nodes
Anterior
axillary nodes
Apical group
Central group
Subareolar plexus of
Sappey
Lateral group
Anterior group
Posterior group
Posterior
intercostal nodes
Internal
mammary
nodes
Fig. 3.19 Lymph nodes draining the breast.
Nipple
Fig. 3.20 Subareolar plexus of Sappey.
Apical group of
axillary lymph nodes
Deltopectoral
lymph node
Central
Groups of axillary
lymph nodes
Lateral
Internal mammary
lymph nodes
Anterior
Posterior
Posterior intercostal
lymph nodes
UL
UM
LL
LM
Breast
Subperitoneal
lymph plexus
Ovary
Krukenbergs tumor
Fig. 3.21 Mode of lymphatic drainage of the breast (UL = upper lateral quadrant, LL = lower lateral quadrant, UM = upper
medial quadrant, LM = lower medial quadrant).
43
44
Lymphatics Draining the Breast

The lymphatics draining the breast are divided into two
groups: (a) superficial and (b) deep.
Superficial lymphatics drain the skin of the breast except
that of nipple and areola.
Deep lymphatics drain the parenchyma of the breast, and
skin of the nipple and areola. A plexus of lymph vessels deep
to the areola is called subareolar plexus of Sappey (Fig. 3.20).
The subareolar plexus and most of the lymph from the breast
drain into the anterior group of axillary lymph nodes.
The superficial lymphatics of the breast of one side
communicate with those of the opposite side. Consequently
the unilateral malignancy may become bilateral.
The lymphatic drainage from the breast occurs as follows
(Fig. 3.21):
1. The lymph from lateral quadrants of the breast is
drained into anterior axillary or pectoral group of lymph
nodes. These lymph nodes are situated deep to the lower
border of pectoralis minor.
2. The lymph from medial quadrants is drained into
internal mammary lymph nodes situated along the
internal mammary artery. Some lymphatics may go to
the internal mammary lymph nodes of the opposite side.
3. A few lymph vessels from the lower lateral quadrant of
the breast follow the posterior intercostal arteries and
drain into posterior intercostal nodes located along the
course of these arteries.
4. The few lymph vessels from the lower medial quadrant
of the breast pierce the anterior abdominal wall and
Axillary
artery
Axillary vein
Apical group of
axillary nodes
Clavipectoral fascia
Fig. 3.22 Direct pathway of deep lymphatics of the breast

through pectoralis major and clavipectoral fascia to the
apical group of axillary nodes.
communicate with subdiaphragmatic and subperitoneal

lymph plexuses.
5. The lymph vessels from the deep surface of the breast
pierce pectoralis major and clavipectoral fascia to drain
into the apical group of axillary lymph nodes (Fig. 3.22).
N.B. About 75% of the lymph from the breast is drained
into axillary nodes, 20% into internal mammary lymph
nodes, and 5% into the posterior intercostal lymph nodes.
Among the axillary lymph nodes, most of the lymph drains
into the anterior axillary nodes and the remaining into
posterior and apical groups. The lymph from anterior and
posterior groups first goes to the central and lateral groups,
and then through them into the supraclavicular lymph nodes.
Breast cancer (carcinoma of the breast): It is one of the
most common cancers in the females. It arises from the
epithelial cells of the lactiferous ducts. In about 60% cases,
it occurs in the upper lateral quadrant and commonly affects
females between 4060 years of age. Clinically it presents
as:
(a) Presence of a painless hard lump.
(b) Breast becomes fixed and immobile, due to infiltration
of suspensory ligaments.
(c) Retraction of skin, due to infiltration of suspensory
ligaments.
(d) Retraction of nipple due to infiltration and fibrosis of
lactiferous ducts.
(e) peau dorange appearance of the skin (i.e., skin giving
rise to appearance like that of the skin of the orange)
due to obstruction of superficial lymphatics.
The knowledge of lymphatic drainage of the breast is of
great clinical importance due to high percentage of
occurrence of cancer in the breast and its subsequent
dissemination of cancer cells (metastasis) along the
lymph vessels to the regional lymph nodes.
In classical operation of radical mastectomy, whole of
breast is removed along with axillary lymph nodes, and
pectoralis major and minor muscles.
Some lymph vessels from the inferomedial quadrant of
the breast communicate with the subperitoneal lymph
plexus and carry cancer cells to it. From here cancer
cells migrate transcoelomically and deposit on the ovary
producing a secondary tumor in ovary called
Krukenbergs tumor.
The cancer of breast is a serious and often a fatal disease
in women. The mammography (Fig. 3.23) and regular
self-examination of the breast help in early detection of
the breast cancer and effective treatment.
The six steps of breast self-examination are as follows
(Fig. 3.24):
1. Stand in front of a long mirror and inspect both breasts
for any discharge from the nipples, puckering, or dimpling
of the skin. Now look for any change in shape or contour
of the breasts.
46
depressed, and gives off 1520 solid cords, which grow in the
underlying mesenchyme and proliferate from lobes of the
gland. At birth, the depressed ectodermal thickening is raised
to form the nipple. The stroma of breast develops from
surrounding mesoderm.
Axilla
Milk line
(line of Schultz)
Mammary
buds
Fully
developed
breast
Accessory
nipples
Groin
Fig. 3.25 Development of the breast. Note the extent of

milk line and possible positions of accessory nipples.
Developmental anomalies of the breast: The following

developmental anomalies of the breasts are encountered
during clinical practice:
Polythelia/supernumerary nipples, which appear along
the milk ridge and is often mistaken for moles.
Retracted nipple/inserted nipple, which occurs if nipple
fails to develop from ectodermal pit. In this condition
suckling of infant cannot take place and nipple is prone to
infection.
Polymastia, the development more than one breast along
the milk line.
Gynecomastia, the development of breast in male,
mainly at puberty. Usually it is bilateral and thought to
occur due to hormonal imbalance.
CHAPTER
Axilla (Armpit)
The axilla or armpit is a fat-filled pyramid-shaped space,

between the upper part of the arm and the side of the chest
wall (Fig. 4.1). It contains the brachial plexus, axillary
vessels, and lymph nodes. It also acts as a funnel shaped
tunnel for neurovascular structures to pass from the root of
the neck to the upper limb and vice versa. Groups of lymph
nodes within it drain the upper limb and the breast. The
study of axilla is clinically important because axillary lymph
nodes are often enlarged and hence routinely palpated
during physical examination of the patient. Abscess in this
region is also common.
BOUNDARIES (Figs 4.24.4)

The axilla resembles a truncated four-sided pyramid and
presents an apex, a base and four walls (anterior, posterior,
medial, and lateral) (Fig. 4.2).
Apex/cervico-axillary canal: It is a passageway between

the neck and axilla. It is directed upwards and medially
into the root of the neck and corresponds to the triangular space bounded in front by the clavicle, behind by the
upper border of the scapula and medially by the outer
border of the first rib (Fig. 4.3). The axillary artery and
brachial plexus enter the axilla from neck through this
gap, hence it is also termed cervico-axillary canal. The
Apex
Lateral wall
Posterior wall
Medial wall
Base
Fig. 4.2 Boundaries of the axilla (Note anterior wall is not

seen).
Cervico-axillary canal
Axilla (armpit)
Upper border of
scapula
Outer border of
first rib
Posterior axillary fold
Anterior axillary fold

Clavicle
Fig. 4.1 Location of the axilla.
Fig. 4.3 Boundaries of the cervico-axillary canal (apex of

the axilla).
Table 4.1 Relations of the axillary artery

Part
Anterior
First part
Second part
Posterior
Pectoralis major
(clavicular part)
Loop of communication
between lateral and
medial pectoral nerves
Pectoralis minor
Medial
Lateral
Medial cord of brachial plexus

Long thoracic nerve
Serratus anterior (first digitation)
Axillary vein
Lateral and posterior

cords of brachial
plexus
Posterior cord of brachial plexus

Subscapularis
Third part
Medial root of median nerve
Radial nerve
Axillary nerve
Subscapularis (in the upper part)
Teres major (in the lower part)
Medial cord of
brachial plexus
Axillary vein
Lateral cord of brachial

plexus
Axillary vein
Medial cutaneous
nerve of forearm
Ulnar nerve
Musculocutaneous
nerve
Subclavian artery
Thoraco-acromial artery
Coracoid process
1s
Superior (supreme)
thoracic artery
2n
d
Axillary artery
Posterior circumflex
humeral artery
Pectoralis minor
Anterior circumflex
humeral artery
3rd
50
Long (lateral)
thoracic artery
Circumflex
scapular artery
Brachial artery
Subscapular artery
Teres major
Fig. 4.5 Course and branches of the axillary artery.
B. From second part

1. Thoraco-acromial artery (acromiothoracic artery),
emerges at the upper border of pectoralis minor,
pierces clavipectoral fascia and soon breaks up into
four branches: (a) pectoral branch, (b) deltoid branch,
(c) acromial branch, and (d) clavicular branch. These
branches radiate at right angle to each other. The
pectoral branch supplies pectoral muscles, deltoid
branch, ends by joining anastomosis over the
acromion, clavicular branch supplied sternoclavicular
joint.
2. Lateral thoracic artery, emerges at and runs along the

inferior border of pectoralis minor, supplying the
branches to pectoralis major and minor and serratus
anterior muscles. In the females, the lateral thoracic
artery is large and provides important supply to the
breast through its lateral mammary branches.
C. From third part
1. Subscapular artery, the largest branch of axillary artery,
runs along the lower border of the subscapularis and
ends near the inferior angle of the scapula. It gives a
Axilla (Armpit)
Pectoralis major
Loop of communication between

medial and lateral pectoral nerves
Pectoralis major
Pectoralis minor
Lateral
pectoral nerve
Lateral cord
Axillary vein
Posterior cord
Medial cord
Long thoracic
nerve
First part of
axillary artery
Axillary vein
Medial pectoral
nerve
Serratus anterior
(first digitation)
Lateral cord
Medial cord
Second part of
axillary artery
Posterior cord
Subscapularis
B
Medial root of
median nerve
Musculocutaneous nerve
Third part of
axillary artery
Axillary nerve
Radial nerve
C
Medial cutaneous
nerve of forearm
Medial cutaneous
nerve of arm
Axillary vein
Ulnar nerve
Subscapularis
Teres major
Fig. 4.6 Relations of the axillary artery: A, first part; B, second part; C, third part.
large branch, the circumflex scapular artery, which

passes through upper triangular intermuscular space,
winds round the lateral border of scapula to enter
infraspinous fossa. In addition, it gives numerous small
branches.
2. Anterior circumflex humeral artery, a small branch,
passes in front of surgical neck of humerus and
anastomoses with the posterior circumflex humeral
artery to form an arterial circle around the surgical neck
of humerus. It gives an ascending branch, which runs
upwards into the intertubercular sulcus of humerus to
supply the head of humerus and shoulder joint.
3. Posterior circumflex humeral artery, larger than the
anterior circumflex humeral artery, passes backwards,
along with axillary nerve through the quadrangular
intermuscular space, crosses the posterior aspect of
surgical neck of humerus to anastomose with the
anterior circumflex humeral artery. It supplies the
deltoid muscle and shoulder joint.
Arterial Anastomosis Around Scapula

(Scapular Anastomosis; Fig. 4.7)
The arterial anastomosis around scapula is principally
formed between the branches of the first part of the
subclavian and the third part of the axillary arteries.
The scapular anastomosis takes place at two sites: around

the body of scapula and over the acromion process of the
scapula.
1. Around the body of scapula: It occurs between the
(a) suprascapular artery, a branch of the thyrocervical
trunk from the first part of the subclavian artery,
(b) circumflex scapular artery, a branch of the
subscapular artery from the third part of the axillary
artery, and
(c) deep branch of the transverse cervical artery, a branch
of the thyrocervical trunk.
2. Over the acromion process: It occurs between the
(a) acromial branch of the thoraco-acromial artery,
(b) acromial branch of the suprascapular artery, and
(c) acromial branch of the posterior circumflex humeral
artery.
Collateral circulation through scapular anastomosis: If
the subclavian and axillary arteries are blocked anywhere
between 1st part of subclavian artery and 3rd part of axillary
artery, the scapular anastomosis serves as a potential
pathway (collateral circulation) between the first part of the
subclavian artery and the third part of the axillary artery, to
ensure the adequate circulation to the upper limb.
51
Axilla (Armpit)
AXILLARY LYMPH NODES (Fig. 4.8)

The axillary lymph nodes are scattered in the fibrofatty tissue
of the axilla. Their number varies between 20 and 30. They
are divided into the following five groups:
1.
Anterior or pectoral group: They lie along the lateral

thoracic vein at the lower border of the pectoralis minor.
They receive the lymph from the upper half of the trunk
anteriorly and from the major part of the breast. The
axillary tail of Spence is in actual contact with these lymph
nodes. Therefore, cancer involving axillary tail of the
breast may be misdiagnosed as an enlarged lymph node.
2. Posterior or subscapular group: They lie on the posterior
axillary fold along the subscapular vein. They receive the
lymph from the upper half of the trunk posteriorly, and
from the axillary tail of the breast.
3. Lateral group: They lie along the upper part of the
humerus in relation to the axillary vein. They drain the
lymph from the upper limb.
4. Central group: They are situated in the upper part of the
axilla. They receive the lymph from the other groups and
drain into the apical group (vide infra). The
intercostobrachial nerve passes amongst these nodes.
Therefore, enlargement of these nodes such as in cancer
may compress this nerve, causing pain in the area of
distribution of this nerve, i.e., along the inner border of
the arm.
5. Apical or infraclavicular group: They are situated deep
to the clavipectoral fascia at the apex of the axilla along
the axillary vein. They are of great clinical importance,
because they receive lymph directly from the upper part
of the breast and indirectly from the rest of the breast
through central group of nodes. They drain into
subclavian lymph trunk on the right side and into the
thoracic duct on the left side. A few efferents from this
group drain into the supraclavicular lymph nodes.
Although these lymph nodes are located very deeply but
can be palpated by pushing the fingers of one hand into
the apex of axilla from below and fingers of the other
hand behind the clavicle from above.
Palpation of axillary lymph nodes: The palpation of
axillary lymph nodes is part of clinical examination of the
breast due to their involvement in cancer breast.
Axillary abscess: An abscess in the axilla arises from
infection and suppuration of the axillary lymph nodes. The
abscess may grow to a considerable size before the
patient feels pain. The pus of axillary abscess may track
into the neck or into the arm if it enters the axillary sheath,
or between the pectoral muscles if it breaks through the
clavipectoral fascia. The axillary abscess is drained by
giving an incision in the floor of axilla, for it being the most
dependant part, midway between the anterior and
posterior axillary folds nearer to the medial wall to avoid
injury to the main vessels running along the anterior,
posterior, and lateral walls of the axilla.
BRACHIAL PLEXUS
The brachial plexus is the plexus of nerves formed by the
anterior (ventral) rami of lower four cervical and the first
thoracic (i.e., C5, C6, C7, C8, and T1) spinal nerves with
little contribution from C4 to T2 spinal nerves.
N.B. If the contribution from C4 is large and that from T2 is
absent, it is called prefixed brachial plexus. On the other
hand, if contribution from T2 is large and that from C4 is
absent, it is termed postfixed brachial plexus.
Components (Fig. 4.9)

The brachial plexus consists of four components: (a) roots,
(b) trunks, (c) divisions, and (d) cords. The roots and trunks
are located in the neck, divisions behind the clavicle and the
cords in the axilla.
Divisions
Cords
Trunks
Roots
C5
C6
C7
N.B. The axillary lymph nodes are also described in terms

of levels at which they are situated, viz.
Level I nodes: They lie lateral to the lower border of
pectoralis minor muscle.
Level II nodes: They lie deep to the pectoralis minor
muscle.
Level III nodes: They lie medial to the upper border of
pectoralis minor muscle.
The lymph nodes first receive the lymph from the area of
breast involved in cancer are termed sentinel lymph nodes.
These are usually the level I lymph nodes. The sentinel
nodes are confirmed by injecting a radioactive substance
into the affected area of the breast.
C8
Key branches
1. Axillary nerve
T1
2. Musculocutaneous
nerve
3. Radial nerve
4. Median nerve
5. Ulnar nerve
Fig. 4.9 Components and key branches of the brachial

plexus.
53
54
Branches (Fig. 4.10)

A. From roots
1. Long thoracic nerve/nerve to serratus anterior (C5, C6,
and C7).
2. Dorsal scapular nerve/nerve to rhomboids (C5).
Roots
The roots (five) are constituted of anterior primary rami of
C5 to T1 spinal nerves. They are located in neck, deep to
scalenus anterior muscle.
Trunks
The trunks (three) are formed as follows:
The C5 and C6 roots join to form the upper trunk; the C7
root alone forms the middle trunk and, C8 and T1 roots join
to form the lower trunk. They lie in the neck occupying the
cleft between scalenus medius behind and the scalenus
anterior in front.
In addition to the long thoracic nerve and dorsal scapular

nerve, branches are given by the roots to supply scalene
muscles and longus colli (C5, C6, C7, and C8) and there is
contribution to phrenic nerve (C5).
B. From trunks
1. Suprascapular nerve (C5 and C6)
2. Nerve to subclavius (C5 and C6)
Divisions
Each trunk divides into anterior and posterior divisions.
They lie behind the clavicle.
N.B. The branches arising from roots and trunks are

supraclavicular branches of brachial plexus.
Cords
C. From cords
The cords (three) are formed as follows: the anterior

divisions of the upper and middle trunks unite to form the
lateral cord and the anterior division of the lower trunk
continues as the medial cord. The posterior divisions of the
three trunks unite to form the posterior cord.
1. From lateral cord

(a) Lateral pectoral nerve (C5, C6, and C7).
(b) Lateral root of median nerve (C5, C6, and C7).
(c) Musculocutaneous nerve (C5, C6, and C7).
Roots
Trunks
DS
C5
Divisions
C6
SS
Cords
C7
NS
Lateral
pectoral nerve
C8
T1
Long thoracic nerve
US
Musculocutaneous
nerve
LS
T
Medial pectoral nerve
Lateral root of
median nerve
Axillary nerve
Radial nerve
Medial cutaneous nerve of arm

Medial cutaneous nerve of forearm
Medial root of median nerve
Median nerve
Ulnar nerve
Fig. 4.10 Brachial plexus and its branches (SS = suprascapular nerve, NS = nerve to subclavius, US = upper subscapular
nerve, LS = lower subscapular nerve, T = thoraco-dorsal nerve, DS = dorsal scapular nerve).
Axilla (Armpit)
2. From medial cord

(a) Medial pectoral nerve (C8 and T1).
(b) Medial cutaneous nerve of arm (T1).
(c) Medial cutaneous nerve of forearm (C8 and T1).
(d) Medial root of median nerve (C8 and T1).
(e) Ulnar nerve (C7, C8, and T1).
3. From posterior cord
(a) Radial nerve (C5, C6, C7, C8, and T1).
(b) Axillary nerve (C5 and C6).
(c) Thoraco-dorsal nerve/nerve to latissimus dorsi (C6,
C7, and C8).
(d) Upper subscapular nerve (C5 and C6).
(e) Lower subscapular nerve (C5 and C6).
N.B. Erbs point (Fig. 4.11): It is the region of upper trunk of
brachial plexus where six nerves meet as follows: 5th and
6th cervical roots join to form the upper trunk, which gives
off two nervessuprascapular and nerve to subclavius, and
then divides into anterior and posterior divisions.
Fig. 4.12 Injury of the upper brachial plexus leading to

excessive increase in the angle between the head and
shoulder: A, fall from the height and landing on a shoulder;
B, Traction of the arm and hyperextension of the neck.
Lesions of the Brachial plexus: For understanding the
effects of the lesions of the brachial plexus, the student
will find it helpful to know the spinal segments, which
control the various movements of the upper limb:
Adduction of the shoulder is controlled by C5 segment.
Abduction of the shoulder is controlled by C6 and C7
segments.
Flexion of the elbow is controlled by C5 and C6
segments.
Extension of the elbow is controlled by C6 and C7
segments.
Flexion of the wrist and fingers is controlled by C8 and
T1 segments.
Fig. 4.13 Policeman receiving a tip position of the upper

limb in Erb's paralysis.
Suprascapular nerve
Anterior
division
C5
C6
Posterior
division
Erbs point
A
Nerve to subclavius
Fig. 4.11 Erbs point.
Fig. 4.14 Injury of the lower brachial plexus leading to

excessive increase in the angle between the trunk and
shoulder: A, sudden upward pull of the arm; B, arm pulled
during delivery.
55
56
Table 4.2 Features of Erbs and Klumpkes paralyses

Erbs paralysis
Klumpkes paralysis
Nerve roots involved
C5 and C6
C8 and T1
Muscles paralyzed
Deltoid, supraspinatus infraspinatus, biceps brachii,

brachialis, brachioradialis, supinator and extensor carpi
radialis longus
All intrinsic muscles of the hand
Position of the upper limb/hand
Policemans tip/Porters tip/Waiters tip position
Claw hand
Sensory loss (sometimes)
Along the outer aspect of the arm
Along the medial border of forearm

and hand
Autonomic signs
Absent
Present (Horners syndrome)
The important lesions of the brachial plexus are as follows:

(a) Erbs paralysis (upper plexus injury): It is caused by
the excessive increase in the angle between the head
and shoulder, which may occur by fall from the back of
horse and landing on shoulder or traction of the arm
during birth of a child (Fig. 4.12). This involves upper
trunk (C5 and C6 roots) and leads to a typical deformity
of the limb called policemans tip hand/porters tip
hand/waiter's tip hand. In this deformity, the arm
hangs by the side, adducted and medially rotated, and
forearm is extended and pronated (Fig. 4.13). The
detailed account of clinical features of Erbs paralysis
is as follows:
Adduction of arm due to paralysis deltoid muscle.
Medial rotation of arm due to paralysis supraspinatus,
infraspinatus, and teres minor muscles.
Extension of elbow, due to paralysis of biceps
brachii.
Pronation of forearm due to paralysis of biceps
brachii.
Loss of sensation (minimal) along the outer aspect
of arm due to involvement of roots of C6 spinal
nerve.
(b) Klumpkes paralysis (lower plexus injury): It is caused by

the hyperabduction of the arm, which may occur when
one falls on an outstretched hand or an arm is pulled into
machinery or during delivery (extended arm in a breech
presentation (Fig. 4.14). The nerve roots involved in this
injury are C8 and T1 and sometimes C7. The clinical
features of Klumpkes paralysis are as follows:
Claw hand, due to paralysis of the flexors of the
wrist and fingers (C6, C7, and C8), and all intrinsic
muscles of the hand (C8 and T1).
Loss of sensations along the medial border of the
forearm and hand (T1).
Horners syndrome, (characterized by partial ptosis,
miosis, anhydrosis, and enophthalmos) due to
involvement of sympathetic fibres supplying head
and neck, which leave the spinal cord through T1.
The important features of Erbs and Klumpkes paralysis
are enumerated in Table 4.2.
Surgical approach to axilla: The axilla is approached
surgically through the skin of the floor of axilla for the
excision of axillary lymph nodes to treat the cancer of the
breast. The structures at risk during this procedure are
(a) intercostobrachial nerve, (b) long thoracic nerve,
(c) thoraco-dorsal nerve, and (d) thoraco-dorsal artery.
Effort should be made to safeguard the above structures.
CHAPTER
Back of the Body and

Scapular Region
The superficial structures on the back of the body are studied

with the upper limb because the shoulder girdle is attached
posteriorly with the axial skeleton by a number of muscles.
These muscles are called posterior axio-appendicular
muscles. They play an important role in the movements of
the scapula. Further removal of the scapula in malignant
disease (e.g., fibrosarcoma) requires detailed knowledge of
the muscles, nerves, and vessels on the back.
Superior nuchal line
SURFACE LANDMARKS (Fig. 5.1)

1. Scapula (shoulder blade) is the most important surface
landmark on the back. It is placed at a tangent on the
posterolateral aspect of the rib cage. Vertically, it extends
from 2nd to 7th rib. Although it is thickly covered by the
muscles, still most of its outline can be felt in the living
individual:
External occipital
protuberance
Nuchal furrow
Crest of spine of scapula
Spine of C7 vertebra
(vertebra prominens)
Spine of T2 vertebra
Acromion process
Medial border of scapula
Scapula
(shoulder blade)
Inferior angle of scapula

7th rib
8th rib
12th rib
Erector spine muscle

Iliac crest
Posterior superior
iliac spine
S2 spine
Coccyx
Natal cleft
Fig. 5.1 Surface landmarks on the back of the body.
(a) Acromion process can be easily felt at the top of the

shoulder.
(b) Crest of the spine of the scapula, runs medially and
slightly downwards from the acromion to the medial
border of the scapula, hence it can be easily palpated
by finger drawn along it.
(c) Medial border can be traced upwards to the superior
angle and downwards to the inferior angle. The
superior angle of the scapula lies opposite the spine
of T2 vertebra, the root of the spine lies at the level
of T3 vertebra and the inferior angle of the scapula
lies at the level of T7 vertebra.
Table 5.1 Approximate levels of some spines on the back

of the body
N.B. The scapula is freely mobile as about 15 muscles are

attached to its processes and fossae. The two scapulae are
drawn apart when the arms are folded across the chest. The
medial borders of the two scapulae are close to the midline
when shoulders are drawn back.
10. Ligamentum nuchae is the median fibrous partition on

the back of neck, which extends from external occipital
protuberance to the spine of C7 vertebra and separates
the short cervical spines from the skin.
2. Eighth rib is palpable, immediately inferior to the

inferior angle of the scapula. The lower ribs can be
counted from it.
3. Twelfth rib can be palpated if it projects beyond the
lateral margin of the erector spinae muscle, about 3 cm
above the iliac crest.
4. Iliac crest is felt as a curved bony ridge below the waist.
When traced forwards and backwards, it ends as anterior
and posterior superior iliac spines, respectively. The
posterior superior iliac spine may be felt in shallow
dimple of skin above the buttock, about 5 cm from the
median line.
5. Sacrumthe back of sacrum lies between the right and
left dimples (vide supra) and its spines can be palpated
in the median plane.
6. Coccyx is a slightly movable bone and may be felt deep
between the buttocks in the natal cleft.
7. Spines of vertebrae lie in the median furrow of the back
and may be felt. The spine of 7th cervical vertebra
(vertebra prominens) is readily felt at the root of the neck
at the lower end of nuchal furrow.
The approximate levels of other spines are given in
Table 5.1.
8. External occipital protuberance and superior nuchal
linesthe external occipital protuberance is a bony
projection felt in the midline on the back of the head.
The curved bony ridge extending laterally on each side
from external occipital protuberance is the superior
nuchal line. These bony features demarcate the junction
between the head and neck posteriorly.
9. Nuchal groove furrow is the median furrow, which
extends from external occipital protuberance to the
spine of C7 vertebra.
CUTANEOUS NERVES (Fig. 5.2)
Vertebral spine
Level
T2
Superior angle of the scapula
T3
Where crest of spine of the scapula meets

its medial border
T7
Inferior angle of the scapula
L4
Highest point of iliac crest
S2
Posterior-superior iliac spine
The cutaneous nerves on the back are derived from the

posterior rami of the spinal nerves. Each primary ramus
divides into medial and lateral branches:
External
occipital
protuberance
Nuchal furrow
Spine of C7
T1
Iliac crest
Fig. 5.2 Cutaneous nerves of the back.
59
60
1. Up to T6, the cutaneous innervation

medial branches, which emerge close
plane.
2. Below T6, the cutaneous innervation
lateral branches, which emerge in line
edge of the erector spinae muscle.
is provided by
to the median
External occipital
protuberance
Medial 1/3rd of
superior nuchal line
is provided by
with the lateral
The cutaneous branches of upper three lumbar nerves

emerge a short distance above the iliac crest and turn down
over it to supply the skin of the gluteal region.
Ligamentum
nuchae
TRAPEZIUS
Clavicle
Acromion
Spine of C7
T1
N.B. The posterior rami of C1, C7, C8, L4, and L5 do not
give any cutaneous branches.
Spine of
scapula
T2
T3
Floor of
bicipital groove
T4
CUTANEOUS ARTERIES
The arteries which accompany the cutaneous nerves on the
back of body in the thoracic and lumbar regions are the
dorsal branches of the posterior intercostal and lumbar
arteries, respectively.
T5
T6
Spines of all
the thoracic
vertebrae
T7
T8
T9
T10
T11
Lower 3 or 4 ribs
T12
POSTERIOR AXIO-APPENDICULAR MUSCLES

(MUSCLES CONNECTING SCAPULA WITH
THE VERTEBRAL COLUMN)
Thoracolumbar fascia
L1
LATISSIMUS DORSI
L2
L3
L4
The muscles that attach the scapula to the back of the trunk
(vertebral column) are arranged in two layers (two in the
superficial layer and three in the deep layer).
L5
Iliac crest
1. Superficial layer of the muscles

(a) Trapezius.
(b) Latissimus dorsi.
2. Deep layer of the muscles
(a) Levator scapulae.
(b) Rhomboideus major.
(c) Rhomboideus minor.
SUPERFICIAL POSTERIOR AXIO-APPENDICULAR

MUSCLES
Trapezius Muscle (Fig. 5.3)
The trapezius is a flat triangular muscle on the back of the
neck and the upper thorax. The muscles of two sides lie side
by side in the midline and together form a diamond shape/
trapezoid shape, hence the name trapezius.
Origin
It arises from:
(a)
(b)
(c)
(d)
(e)
medial third of the superior nuchal line,

external occipital protuberance,
ligamentum nuchae,
spine of 7th cervical vertebra, and
spines of all thoracic vertebrae.
Fig. 5.3 Origin and insertion of the trapezius and latissimus

dorsi muscles.
Insertion
The insertion occurs as follows:
1. The superior fibres runs downwards and laterally to be
inserted on to the posterior border of the lateral third of
the clavicle.
2. The middle fibres proceed horizontally to be inserted on
to the medial margin of the acromion and upper lip of
the crest of the spine of the scapula.
3. The lower fibres pass upward and laterally to be inserted
on to the deltoid tubercle at the junction of medial and
middle third of the spine of the scapula.
Nerve supply
It is by:
(a) spinal part of the accessory nerve (provides motor
supply), and
(b) ventral rami of C3 and C4 (carry proprioceptive
sensations).
Actions
1. The upper fibres of trapezius along with levator scapulae
elevate the scapula as in shrugging the shoulder.
2. The middle fibres of trapezius along with rhomboids
retract the scapula as in bracing back the shoulder.
3. The lower fibres of trapezius depress the medial part of
the spine of the scapula.
4. Acting with serratus anterior, the trapezius rotates the
scapula forward so that the arm can be abducted beyond
90.
Clinical testing
Palpate the trapezius while the shoulder is shrugged against
the resistance. Inability to shrug (to raise) the shoulder is
suggestive of muscle weakness.
Latissimus Dorsi (L. Latissimus = widest, Dorsi = back)

The latissimus dorsi is a wide, flat, triangular muscle on the
back (lumbar region and lower thorax). It is mostly
superficial except a small portion, covered posteriorly by the
lower part of trapezius.
Origin
It arises from:
(a) spines of lower six thoracic vertebrae anterior to the
trapezius, by tendinous fibres,
(b) posterior lamina of thoraco-lumbar fascia (by which it is
attached to the spines of lumbar and sacral vertebrae) by
tendinous fibres,
(c) outer lip of the posterior part of the iliac crest by
muscular slips,
(d) lower three or four ribs by fleshy slips,
(e) inferior angle of the scapula.
Insertion
From its extensive origin the fibres pass laterally with
different degrees of obliquity (the upper fibres are nearly
horizontal, the middle are oblique, and lower are almost
vertical) to form a sheet that overlaps the inferior angle of
the scapula. This sheet curves around the inferolateral border
of the teres major to gain its anterior surface. Here it ends as
flattened tendon, which is inserted into the floor of
intertubercular sulcus (bicipital groove) of the humerus.
The latissimus dorsi and teres major together form the
posterior axillary fold.
Nerve supply
The latissimus dorsi is supplied by thoraco-dorsal nerve from
the posterior cord of the brachial plexus.
Actions
1. Latissimus dorsi is active in adduction, extension, and
rotation, especially medial rotation of the humerus.
2. It pulls up the trunk upwards and forwards during

climbing. This action is in conjunction with the
pectoralis major muscle.
3. It assists backward swinging of the arm during walking.
4. It takes part in all violent expiratory efforts.
N.B. Because of its attachment on the ilium and sacrum, the
latissimus dorsi is able to elevate the pelvis if the arms are
stabilized. This action occurs when the arms are stabilized
on crutch-handles. This is a very good example of reversal
of muscle action where proximal attachment (i.e., origin)
pulls the distal attachment (i.e., insertion).
Clinical testing
The posterior axillary fold becomes accentuated when a 90
abducted arm is adducted against the resistance or when
patient coughs violently.
Musculocutaneous flap of latissimus dorsi: The
latissimus dorsi is supplied by a single dominant vascular
pedicle formed by the thoraco-dorsal artery, a continuation
of the subscapular artery. This artery and its accompanying
venae comitantes and thoraco-dorsal nerve descend in
the posterior wall of axilla and enter the costal surface of
the muscle at a single neuro-vascular hilum about 14cm
medial to the lateral border of the muscle. The presence of
single dominant vascular pedicle provides the anatomical
basis for raising the muscle above, or along with the
overlying skin in the form of musculocutaneous flap. The
musculocutaneous flap of latissimus dorsi is often used in
reconstructing a breast following mastectomy.
Conditioning of latissimus dorsi to act as a cardiac
muscle: The latissimus dorsi if conditioned with pulsated
electrical impulses, starts functioning like a cardiac
muscle, i.e., it will be non-fatigable and use oxygen at a
steady pace. Thus following conditioning, the latissimus
dorsi can be used as an autotransplant to repair a
surgically removed portion of heart. The procedure
involves detaching the latissimus dorsi from its vertebral
origin keeping the neurovascular pedicle intact and
slipping it into the pericardial cavity, where it is wrapped
around the heart like a towel. A pacemaker is required to
provide the continuous rhythmic contractions.
DEEP POSTERIOR AXIO-APPENDICULAR

MUSCLES (Fig. 5.4)
Levator Scapulae
Origin
The levator scapula is a slender muscle. It arises by tendinous
slips from
(a) transverse processes of atlas and axis vertebrae, and
(b) posterior tubercles of the transverse processes of the 3rd
and 4th cervical vertebrae.
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Table 5.2 Origin, insertion, nerve supply, and actions of the muscles connecting scapula with the vertebral column
Muscle
Origin
Trapezius
Spines of T7T12 vertebrae

Thoraco-lumbar fascia
Iliac crest
Lower 3 or 4 ribs
Inferior angle of the scapula
Floor of intertubercular
sulcus of the humerus
Transverse processes of C1C4

vertebrae
Medial border of the

scapula between the
superior angle and root
of spine
Base of triangular area at

the root of spine of the
scapula
Levator scapulae
Rhomboideus
minor
Rhomboideus
major
Nerve supply
Medial 1/3rd of superior

nuchal line
Ligamentum nuchae
External occipital
protuberance
Spines of C7T12 vertebrae
Latissimus dorsi
Insertion
Lower part of the ligamentum

nuchae
Spines of C7 and T1 vertebrae
Spines of T2T5 vertebrae
Clavicle
Lateral 1/3rd of clavicle

Medial margin of
acromion
Superior margin of
spine of the scapula
Spinal accessory
(motor)
C3, C4 spinal
nerves
(proprioceptive)
Thoraco-dorsal nerve
(C6, C7, C8)
2. Lateral margin of
acromion
Acromion
3. Crest of
spine of
scapula
Upper fibres elevates the

scapula
Middle fibres retract the
scapula
Lower fibres depress the
scapula
Adduction,
Extension and medial
rotation of the arm
Raises body towards arm
as in climbing
Dorsal scapular
nerve (C5)
C3 and C4 spinal
nerves
(proprioceptive)
Elevation and medial

rotation of the scapula and
tilts its glenoid cavity
inferiorly
Dorsal scapular
nerve (C5)
Retraction and elevation of

the scapula
Medial border of the

Dorsal scapular nerve
scapula from root of
(C5)
spine to the inferior angle
Origin
1. Lateral 1/3rd of
clavicle
Spine of scapula
Actions
Retraction, medial rotation,

and elevation of the
scapula
converge onto the three septa of insertion, which are

attached to the deltoid tuberosity. Due to multipennate
arrangement, the middle acromial part of the deltoid is the
strongest part (Fig. 5.8).
Nerve supply
The deltoid is supplied by the axillary nerve (C5 and C6).
Acromion process
DELTOID
Intramuscular
septum of origin
Unipennate
posterior
fibres
Shaft of
humerus
Insertion
V-shaped deltoid
tuberosity of humerus
Unipennate
anterior fibres
Multipennate
lateral fibres
Intramuscular
septum of
insertion
Deltoid tuberosity of
humerus
Fig. 5.7 Origin and insertion of the deltoid muscle.
Fig. 5.8 Architecture of the deltoid muscle.
Actions
Supraspinatus
1. The anterior (clavicular) fibres are flexors and medial

rotators of the arm.
2. The posterior (spinous) fibres are the extensors and
lateral rotators of the arm.
3. The middle (acromial) fibres are the strong abductor of
the arm from 15 to 90.
Supraspinatus
Infraspinatus
Teres minor
Middle (acromial) fibres cannot abduct the arm from 0

to 15 when the arm is by the side of body because its vertical
pull corresponds to the long axis of the arm.
TM
Teres major
N.B. The deltoid muscle is like three muscles in one: the

anterior fibres flex the arm, lateral fibres abduct the arm and
posterior fibres extend the arm.
Clinical testing
The deltoid can be easily seen and felt to contract when the
arm is abducted against resistance.
Site of the intramuscular injection in deltoid: The
intramuscular injections are commonly given in the lower
half of the deltoid to avoid injury to the axillary nerve, which
winds around the surgical neck of the humerus.
N.B. In actual clinical practice, the intramuscular injection is

given in the upper and outer quadrant of the deltoid region.
Structures under cover of deltoid

Bones: Upper end of the humerus and coracoid process.

Joints and ligaments: Shoulder (glenohumeral) joint and
coracoacromial ligament.
Bursae around the shoulder joint: Subscapular, subacromial/
subdeltoid, and infraspinatus.
Muscles:
(a) Insertions of pectoralis minor, pectoralis major, teres
major, latissimus dorsi, subscapularis, supraspinatus,
infraspinatus, and teres minor.
(b) Origins of long head of biceps, short head of biceps,
coracobrachialis, long and lateral heads of triceps.
Vessels: Anterior and posterior circumflex humeral.
Nerves: Axillary nerve.
Spaces: Quadrangular and triangular subscapular
intermuscular spaces.
Supraspinatus (Fig. 5.9)

Origin
Supraspinatus arises from medial two-third of the
supraspinous fossa of the scapula.
Insertion
The fibres pass forward and converge under the acromion,
into a tendon, which crosses above the shoulder joint and is
Teres major
Infraspinatus
Fig. 5.9 Origin and insertion of the supraspinatus,

infraspinatus, teres minor, and teres major muscles
(TM=teres minor).
inserted on to the superior facet on the greater tubercle of

the humerus.
Nerve supply
Supraspinatus is supplied by the suprascapular nerve (C5 and
C6).
Actions
Supraspinatus initiates the abduction of shoulder. It is
responsible for first 15 of abduction of the shoulder and
thus assists the deltoid in carrying abduction thereafter, i.e.,
from 15 to 90.
Clinical testing
The supraspinatus can be palpated deep to the trapezius and
above the spine of the scapula when the arm is abducted
against the resistance.
Rupture of supraspinatus tendon: It is a common soft
tissue injury in the shoulder region. The patient with ruptured
supraspinatus tendon when asked to raise his hand above
the head on the affected side, he will first tilt his body on the
affected side so that arm swings away from the body leading
to an initial abduction of 15 or he will slightly (about 15)
raise the affected arm by the hand of the healthy sidea
common trick-device learned by the patients with ruptured
supraspinatus tendon.
Infraspinatus (Fig. 5.9)

It is a thick triangular muscle, which occupies most of the
infraspinous fossa.
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66
Origin
It arises from the medial two-third of the fossa by tendinous
fibres from ridges on its surface.
Insertion
Its fibres converge to form a tendon, which passes across the
posterior aspect of the shoulder joint to be inserted on to the
middle facet of the greater tubercle of the humerus.
Origin
Subscapular
fossa and
tendinous
intramuscular
septa
Nerve supply
Infraspinatus is supplied by the suprascapular nerve (C5 and
C6).
Action
Infraspinatus is the lateral rotator of the humerus.
Clinical testing
The infraspinatus can be palpated inferior to the spine of
the scapula when the arm is laterally rotated against the
resistance.
Teres Minor (Fig. 5.9)

Origin
This narrow elongated muscle arises from posterior aspect of
the lateral border of the scapula.
Insertion
The fibres run upwards and laterally across the shoulder
joint to be inserted on to the lower facet of the greater
tubercle of the humerus.
Nerve supply
Teres minor is supplied by a branch of the axillary nerve (C5
and C6). The nerve to teres minor possesses a pseudoganglion.
Actions
Teres minor acts as a lateral rotator and weak adductor of the
humerus.
Teres Major (Fig. 5.9)

Origin
This thick flat muscle arises from the oval area on the dorsal
surface of the inferior angle and adjoining lateral border of
the scapula.
Insertion
The fibres run upwards and laterally, and end in a flat tendon,
which is inserted on to the medial lip of the intertubercular
sulcus of the humerus.
Nerve supply
Teres major is supplied by the lower subscapular nerve (C5,
C6, and C7).
Action
Teres major acts as a medial rotator of the arm.
Insertion
Lesser tubercle of
humerus
Fig. 5.10 Origin and insertion of the subscapularis muscle.
Subscapularis (Fig. 5.10)

It is a bulky triangular muscle, which fills the subscapular
fossa.
Origin
Subscapularis arises from (a) medial two-third of the costal
surface of the scapula and (b) tendinous intermuscular septa
attached to the ridges on the bone.
Insertion
The fibres converge laterally into a broad tendon, which
passes in front of the capsule of glenohumeral joint to be
inserted on to the lesser tubercle of the humerus. The tendon
is separated from the neck of the scapula by a large
subscapular bursa, which generally communicates with the
synovial cavity of the shoulder joint.
Nerve supply
The subscapularis is supplied by the upper and lower
subscapular nerves (C5, C6).
Actions
Subscapularis is the medial rotator of the humerus.
Together with supraspinatus, infraspinatus, and teres minor
it stabilizes the head of the humerus in glenoid fossa during
shoulder movements.
The origin, insertion, nerve supply, and actions of the
scapulohumeral muscles are described in Table 5.3.
ROTATOR CUFF MUSCLES

The four of scapulohumeral muscles, viz. supraspinatus
infraspinatus, teres minor, and subscapularis (often referred
to as SITS muscles) are called rotator cuff muscles for
they form musculotendinous/rotator cuff around the
glenohumeral joint.
Table 5.3 Origin, insertion, nerve supply, and actions of the scapulohumeral muscles
Muscle
Origin
Deltoid
(a) Clavicular part
unipennate
(b) Acromial part
multipennate
(c) Spinous part
unipennate
Nerve supply
Actions
Anterior aspect of
Deltoid tuberosity of
lateral 1/3rd of clavicle humerus
Lateral border of
acromion
Lower lip of the spine
of scapula
Axillary nerve (C5, C6)
Supraspinatus
(multipennate)
Medial 2/3rd of the

supraspinous fossa of
scapula
Superior facet of greater

tubercle of the humerus
Suprascapular nerve (C5, Initiates abduction of the

C6)
arm and carries it up to 15
Infraspinatus
(multipennate)
Medial 2/3rd of the

infraspinous fossa of
scapula
Middle facet of greater

Suprascapular nerve (C5, Lateral rotation of the arm

C6)
Teres minor
Upper 2/3rd of the

dorsal aspect of the
lateral border of scapula
Inferior facet of greater

Axillary nerve (C5, C6)
Lateral rotation of the arm
Teres major
Inferior 1/3rd of the

dorsal aspect of the
lateral border and
inferior angle of scapula
Medial lip of the

intertubercular sulcus of
the humerus
Lower subscapular nerve

(C5, C6)
Abduction and medial

rotation of the arm
Subscapularis
(multipennate)
Lesser tubercle of the

humerus
Upper and lower

subscapular nerves (C5,
C6, C7)
Medial 2/3rd of the

subscapular fossa
Tendinous
intermuscular septa
Insertion
ROTATOR CUFF (MUSCULOTENDINOUS CUFF)

The rotator cuff (Fig. 5.11) is the name given to the tendons
of supraspinatus, infraspinatus, teres minor, and
subscapularis which are fused with the underlying capsule of
the glenohumeral joint. Tendon of supraspinatus fuse
superiorly, tendons of infraspinatus and teres minor fuse
posteriorly, and that of subscapularis fuse anteriorly. This
cuff plays an important role in stabilizing the shoulder joint.
The primary function of rotator cuff muscles is to grasp the
relatively large head of humerus and hold it against the smaller,
shallow glenoid cavity (Fig. 6.8A).
MOVEMENTS OF THE SCAPULA (Fig. 5.12)

The scapula is able to glide freely on the posterior chest wall
because of the loose connective tissue between the serratus
anterior and the chest wall.
The movements of scapula are produced by the muscles
that attach it to the trunk and indirectly by the muscles
passing from trunk to the humerus when the glenohumeral
joint is fixed.
Flexion and medial

rotation by the anterior
fibres
Abduction (1590) of
the arm by middle fibres
Extension and medial
rotation of the arm by
posterior fibres
Adduction and medial

rotation of the arm
Helps to hold the humeral
head in glenoid cavity
Supraspinatus
Infraspinatus
Joint cavity
Gap in the
joint capsule for
subscapular bursa
Subscapularis
Teres minor
Glenoid cavity
Capsule of
shoulder joint
Glenoid labrum
Fig. 5.11 Musculotendinous (rotator) cuff.
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Upper fibres of
trapezius
Middle fibres of
trapezius
Levator
scapulae
Rhomboideus
minor
Pectoralis
minor
Rhomboideus
major
Serratus
anterior
A
Protraction
Retraction
Levator scapulae
Elevation
Upper fibres of
trapezius
Rhomboideus
minor
Trapezius
lower fibres
Latissimus
dorsi
Serratus anterior
(lower 5 digitations)
Rhomboideus
major
Weight of
limb
Lower fibres of
trapezius
Pectoralis minor
D
Depression
Medial rotation
Lateral rotation
Fig. 5.12 Movements of the scapula (AF).
All the movements of scapula occurring on the chest wall

(scapulothoracic linkage) involves concomitant movements
at sternoclavicular and acromioclavicular joints.
The various movements of the scapula are as follows:
1.
2.
3.
4.
5.
Protraction.
Retraction.
Elevation.
Depression.
Rotation (lateral and medial).
Protraction: In this movement, scapula moves forwards on

the chest wall. It is produced by serratus anterior assisted by
the pectoralis minor muscle. Protraction is required for
punching (e.g., boxing), pushing, and reaching forwards.
Retraction: In this movement, the scapulae are drawn
backwards towards the median plane in bracing back of the
shoulders. It is produced by middle fibres of trapezius and
rhomboids.
Elevation: The scapula is elevated, as in shrugging, by
simultaneous contraction of the levator scapulae and upper
fibres of the trapezius.
Depression: The scapula is depressed by simultaneous

contraction of the pectoralis minor, lower fibres of trapezius,
and latissimus dorsi.
Rotation: The rotation of scapula takes place around the
horizontal axis passing through the middle of the spine of
scapula and sternoclavicular joint.
1. Medial rotation is brought about by simultaneous
contraction of levator scapulae, rhomboids, and
latissimus dorsi. The gravity (e.g., weight of the upper
limb) plays a key role in this movement.
2. Lateral rotation is brought about by the trapezius (its
upper fibres raise the acromion process and its lower
fibres depress the medial end of the spine of the scapula)
and serratus anterior (its lower 5 digitations pull the
inferior angle of the scapula forwards and laterally). The
lateral rotation of the scapula tilts its glenoid cavity
upwardswhich is essential for abduction of the upper
limb above 90.
The movements of scapula and the muscles, which
produce them are summarized in Table 5.4 and Figure 5.12.
70
NERVES AND VESSELS

AXILLARY NERVE (Fig. 5.15)
The axillary nerve (C5, C6) arises from the posterior cord of
the brachial plexus near the lower border of the subscapularis.
It runs backwards on subscapularis to pass through the
quadrangular space along with the posterior circumflex
humeral artery. Here it is intimately related to the medial
aspect of the surgical neck of the humerus immediately
inferior to the capsule of the shoulder joint. The nerve gives
a branch to the shoulder joint, and then runs laterally to
divide into the anterior and posterior divisions/branches,
deep to deltoid.
The posterior branch supplies teres minor and posterior
part of the deltoid. It then continues over the posterior
border of the deltoid as upper lateral cutaneous nerve of the
Anterior circumflex
humeral artery
arm and supplies the skin over the lower half of the deltoid.
The nerve to teres minor possesses a pseudoganglion.
The anterior branch continues horizontally between the
deltoid and surgical neck of the humerus with posterior
circumflex humeral vessels. It supplies deltoid and sends a
few branches through it to innervate the overlying skin.
Injury of the axillary nerve: The axillary nerve is at risk of
damage in inferior dislocation of the head of humerus from
shoulder joint and in fractures of the surgical neck of the
humerus because of its close relation to these structures
(Fig. 6.2B). The damage of axillary nerve presents the
following clinical features:
Impaired abduction of the shoulderdue to paralysis of
the deltoid and teres minor muscles.
Loss of sensations over the lower half of the deltoid
(regimental badge area of the sensory loss)due to
involvement of the upper lateral cutaneous nerve of the arm.
Loss of shoulder contour with prominence of greater
tubercle of the humerusdue to wasting of the deltoid
muscle.
Axillary artery
humeral artery
CIRCUMFLEX HUMERAL ARTERIES
Axillary nerve
Posterior branch
Nerve to
teres minor
These arteries arise from the third part of the axillary artery
and together form a circular anastomosis around the surgical
neck of the humerus.
Humerus
Deltoid
muscle
Pseudoganglion
Anterior branch
Upper lateral cutaneous

nerve of arm
Fig. 5.15 Axillary nerve as seen in the horizontal section of

deltoid region at the level of surgical neck of the humerus.
ARTERIAL ANASTOMOSIS AROUND THE SCAPULA

This anastomosis is clinically important because it ensures
adequate arterial supply to scapula and provides a subsidiary
route through which the blood can pass from the first part of
the subclavian artery to the third part of the axillary artery
when either the subclavian artery or axillary artery is blocked
between these two sites (for details see Chapter 4, pages 51
and 52).
CHAPTER
Shoulder Joint Complex

(Joints of Shoulder Girdle)
The shoulder joint complex consists of four basic

articulations, namely (Fig. 6.1),
1.
2.
3.
4.
Glenohumeral joint.
Acromioclavicular joint.
Sternoclavicular joint.
Scapulothoracic articulation/scapulothoracic linkage
(functional linkage between the scapula and thorax).
Normal function of the shoulder girdle requires smooth

coordination of movements on all these joints. The
impairment of any one of these joints leads to functional
defect of the whole complex.
The main function of the shoulder in man is to enable

him to place his hand where he wishes to in a coordinated
and controlled manner.
From weight-bearing forelimb of a quadruped to a freely
mobile upper limb in human beings, substantial phylogenetic
changes have occurred in the shoulder girdle. In human
beings, shoulder girdle has sacrificed stability for mobility,
which is responsible for most of the pathological changes
that take place in it.
The glenohumeral joint is the primary articulation of the
shoulder girdle and generally termed shoulder joint by the
clinicians. It is quite commonly affected by disease hence it
needs to be described in detail.
Acromioclavicular
joint
Glenohumeral
joint
SHOULDER JOINT (GLENOHUMERAL JOINT)

It is a joint between the head of humerus and glenoid cavity
of the scapula.
The shoulder joint is the most movable joint of the body
and consequently one of the least stable. It is most common
joint to dislocate and to undergo recurrent dislocations.
Therefore, the students must study it very thoroughly.
Type
Scapulothoracic
linkage
The shoulder joint is a ball-and-socket type of synovial joint

(Fig. 6.2).
ARTICULAR SURFACES (Fig. 6.2)

The shoulder joint is formed by articulation of large round
head of humerus with the relatively shallow glenoid cavity
of the scapula. The glenoid cavity is deepened slightly but
effectively by the fibrocartilaginous ring called glenoid
labrum.
LIGAMENTS (Figs 6.36.5)

Fig. 6.1 Articulations of the shoulder complex (joints of the
shoulder girdle).
The ligaments of the shoulder joint are as follows:
Coracoacromial arch
Glenoid cavity of
scapula
Acromion
Acromion
process
Clavicle
Coracoacromial
ligament
Coracoid
process
Supraspinatus
Subacromial/
subdeltoid bursa
Glenoid cavity of
scapula
Deltoid
Glenoid labrum
Joint capsule
humeral artery
Axillary nerve
Head of humerus
A
Fig. 6.2 Shoulder joint: A, a radiograph showing articular surfaces; B, coronal section. (Source: Fig. 7.25, Page 628, Grays
Anatomy for Students, Richard L Drake, Wayne Vogl, Adam WM Mitchell. Copyright Elsevier Inc. 2005, All rights reserved.)
1. Capsular ligament (joint capsule): The thin fibrous

layer of the joint capsule surrounds the glenohumeral
joint. It is attached medially to the margins of the
glenoid cavity beyond the glenoid labrum and laterally
to the anatomical neck of the humerus, except inferiorly
where it extends downwards 1.5 cm or more on the
surgical neck of the humerus. Medially the attachment
extends beyond the supraglenoid tubercle thus
Long head of
biceps brachii
Glenoid labrum
enclosing the long head of biceps brachii within the

joint cavity.
A portion of epiphyseal line of proximal humerus is
intracapsular, therefore, septic arthritis of the shoulder joint
may occur following metaphyseal osteomyelitis.
Acromion
Coracoacromial
ligament
Coracohumeral
ligament
Transverse
humeral
ligament
Coracoid
process
Superior
Glenohumeral
ligaments
Middle
Inferior
Capsule of
glenohumeral joint
Fig. 6.3 Interior of the shoulder joint exposed from behind

to show the glenohumeral ligaments.
Bicipital
groove
Joint capsule
Fig. 6.4 Coracoacromial, coracohumeral, and transverse

humeral ligaments as seen from the anterior aspect.
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74
Acromion process
Coracoacromial
ligament
Coracoid
process
Transverse
humeral
ligament
Synovial
sheath around
the tendon of
biceps
and lesser tubercles. This ligament converts the groove

into a canal that provides passage to the tendon of long
head of biceps surrounded by a synovial sheath.
ACCESSORY LIGAMENTS
The accessory ligaments of the shoulder joint are as follows:
Subscapular
bursa
Synovial
membrane
Tendon of
long head of
biceps brachii
Fig. 6.5 Synovial membrane lining the interior of shoulder

joint and its extensions.
The synovial membrane lines the inner surface of the

joint capsule and reflects from it to the glenoid labrum
and humerus as far as the articular margin of the head.
The synovial cavity of the joint presents the following
features:
(a) It forms tubular sheath around the tendon of biceps
brachii where it lies in the bicipital groove of the
humerus.
(b) It communicates with subscapular and infraspinatus
bursae, around the joint.
Thus there are three apertures in the joint capsule:
(a) An opening between the tubercles of the humerus
for the passage of tendon of long head of biceps
brachii.
(b) An opening situated anteriorly inferior to the
coracoid process to allow communication between
the synovial cavity and subscapular bursa.
(c) An opening situated posteriorly to allow
communication between synovial cavity and
infraspinatus bursa.
2. Glenohumeral ligaments: There are three thickenings
in the anterior part of the fibrous capsule; to strengthen
it. These are called superior, middle, and inferior
glenohumeral ligaments. They are visible only from
interior of the joint.
A defect exists between superior and middle
glenohumeral ligaments, which acquire importance in
the anterior dislocation of the shoulder joint.
3. Coracohumeral ligament: It is a strong band of fibrous
tissue that passes from the base of the coracoid process
to the anterior aspect of the greater tubercle of the
humerus.
4. Transverse humeral ligament: It is a broad fibrous band,
which bridges the bicipital groove between the greater
1. Coracoacromial ligament: It extends between coracoid

and acromion processes. It protects the superior aspect
of the joint.
2. Coracoacromial arch: The coracoacromial arch is formed
by coracoid process, acromion process, and coracoacromial
ligament between them. This osseoligamentous structure
forms a protective arch for the head of humerus above
and prevents its superior displacement above the glenoid
cavity. The supraspinatus muscle passes under this arch
and lies deep to the deltoid where its tendon blends with
the joint capsule. The large subacromial bursa lies
between the arch superiorly and tendon of supraspinatus
and greater tubercle of humerus inferiorly. This facilitates
the movement of supraspinatus tendon.
BURSAE RELATED TO THE SHOULDER JOINT

Several bursae are related to the shoulder joint but the
important ones are as follows (Fig. 6.6):
1. Subscapular bursa: It lies between the tendon of
subscapularis and the neck of the scapula; and protects
the tendon from friction against the neck. This bursa
usually communicates with the joint cavity.
2. Subacromial bursa (Fig. 6.7): It lies between the
coracoacromial ligament and acromion process above,
and supraspinatus tendon and joint capsule below. It
continues downwards beneath the deltoid, hence it is
sometimes also referred to as subdeltoid bursa. It is the
largest synovial bursa in the body and facilitates the
movements of supraspinatus tendon under the
coracoacromial arch.
3. Infraspinatus bursa: It lies between the tendon of
infraspinatus and posterolateral aspect of the joint
capsule. It may sometime communicate with the joint
cavity.
N.B. The bursae around the shoulder joint are clinically
important as some of them communicate with synovial
cavity of the joint. Consequently, opening a bursa may mean
entering into the cavity of the joint.
RELATIONS OF THE SHOULDER JOINT (Fig. 6.6)

The shoulder joint is related:
Superiorly: to coracoacromial arch, subacromial bursa,
supraspinatus muscle, and deltoid muscle.
76
Deltoid
Supraspinatus
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Subscapularis
Infraspinatus
Humerus
Teres minor
Fig. 6.8 Action of the rotator cuff muscles: A, they grasp and pull the relatively large head of the humerus medially to hold
it against the smaller and shallow glenoid cavity; B, combined function of the rotator cuff muscles and deltoid.
The coracoacromial arch forms, the secondary socket of

the glenohumeral joint and protects the joint from the above
and prevents the upward dislocation of the head of humerus.
The long head of biceps brachii, passes above the head of
humerus intracapsular, hence prevents its upward
displacement.
The glenoid labrum provides protection by deepening the
shallow glenoid cavity.
on
cti
Ad
du
cti
du
Ab
MOVEMENTS OF THE SHOULDER JOINT

(Figs 6.9 and 6.10)
The shoulder joint has more freedom of mobility than any
other joint in the body, due to the following factors:
on
Flexion
Extension
1. Laxity of joint capsule.

2. Articulation between relatively large humeral head and
smaller and shallow glenoid cavity.
Medial
rotation
Lateral
rotation
The glenohumeral joint permits four groups of movements:

1.
2.
3.
4.
Flexion and extension.

Abduction and adduction.
Medial and lateral rotation.
Circumduction.
The movements of shoulder joint occur in all the three

planes and around all the three axes:

The flexion and extension/hyperextension occur in

sagittal plane around the frontal axis.
The abduction and adduction occur in frontal plane
around the sagittal axis.
Fig. 6.9 Planes of movements of the shoulder joint:

A, planes of flexion and extension, and abduction and
adduction; B, plane of medial and lateral rotation.
Abduction
Flexion
Adduction
Extension
Abduction
Flexion
Extension
Medial rotation
Lateral rotation
Circumduction
Adduction
Fig. 6.10 Movements of the shoulder joint. (Source: Fig. 7.4, Page 611, Grays Anatomy for Students, Richard L Drake, Wayne
Vogl, Adam WM Mitchell. Copyright Elsevier Inc. 2005, All rights reserved.)

The medial and lateral rotation occur in transverse plane

around the vertical axis.
The circumduction is really only a combination of all
above movements.
N.B. Plane of the glenohumeral joint: The scapula does not

lie in the coronal plane but is so oriented that its glenoid
cavity faces forwards and laterally, therefore the plane of this
joint lies obliquely at about 45 to the sagittal plane. The
movements of shoulder joint are, therefore, described in
relation to this plane.
The details are as under:

1. Flexion and extension: During flexion, the arm moves
forwards and medially, and during extension it moves
backwards and laterally. These movements take place
parallel to the plane of glenoid cavity (i.e., midway
between the coronal and sagittal plane).
2. Abduction and adduction: During abduction, the arm

moves anterolaterally away from the trunk and during
adduction the arm moves posteromedially towards the
trunk. These movements occur at right angle to the
plane of flexion and extension (i.e., in the plane of the
body of the scapula).
3. Medial and lateral rotation: These movements are best
demonstrated in midflexed elbow. In this position, the
hand moves medially in medial rotation and laterally in
lateral rotation.
4. Circumduction: The circumduction at glenohumeral
joint is an orderly sequence of flexion, abduction,
extension and adduction or the reverse. During this
movement the upper limb moves along a circle.
The muscles producing the various movements at the
shoulder joint are listed in Table 6.1.
77
78
Table 6.1 Movements at the shoulder joint and muscles producing them
Movements
Main muscles (prime movers)
Flexion
Pectoralis major (clavicular part)

Deltoid (anterior fibres)
Accessory muscles (synergists)
Extension
Adduction
Deltoid (posterior fibres)

Latissimus dorsi
Pectoralis major (sternocostal part)

Latissimus dorsi
Abduction
Medial rotation
Deltoid (lateral fibres)

Supraspinatus
Subscapularis
Lateral rotation
Deltoid (posterior fibres)
Mechanism of Abduction
The abduction at shoulder is a complex movement, hence
student must understand it.
The total range of abduction is 180. Abduction up to 90
occurs at the glenohumeral joint. Abduction from 90 to
120 can occur only if the humerus is rotated laterally.
Abduction from 120 to 180 can occur if the scapula rotates
forwards on the chest wall.
The detailed analysis is as under:
1. The articular surface of the head of humerus permits
elevation of arm only up to 90, because when the upper
end of humerus is elevated, to 90 its greater tubercle
impinges upon the under surface of the acromion and
can only be released by lateral rotation of the arm.
2. Therefore, the arm rotates laterally and carries abduction
up to 120.
3. Abduction above 120 can occur only if scapula rotates.
So that the scapula rotates forwards on the chest wall.
N.B.
The humerus and scapula move in the ratio of 2:1 during
abduction, i.e., for every 15 elevation, the humerus
moves 10 and scapula moves 5.
During early and terminal stages of elevation, the
sternoclavicular and acromioclavicular joints move
maximum, respectively.
Range of motion (ROM) of various movements

During clinical examination, the knowledge of range of
motion of various movements is very important. It is given
in the box below:
Biceps brachii (short head)

Coracobrachialis
Sternocostal head of pectoralis major
Teres major
Teres major
Coracobrachialis
Short head of biceps
Serratus anterior
Upper and lower fibres of trapezius
Pectoralis major
Latissimus dorsi
Deltoid (anterior fibres)
Teres major
Infraspinatus
Teres minor
Movements
Range of motion
Flexion
90
Extension
45
Abduction
180
Adduction
45
Lateral rotation
45
Medial rotation
55
Dislocation of the shoulder joint: Dislocation of
shoulder joint mostly occurs inferiorly because the joint is
least supported on this aspect. It often injures the axillary
nerve because of its close relation to the inferior part of
the joint capsule. However, clinically, it is described as
anterior or posterior dislocation indicating whether the
humeral head has descended anterior or posterior or to
the infraglenoid tubercle of the scapula and long head of
the triceps.
The dislocation is usually caused by excessive extension
and lateral rotation of the humerus.
Clinically, it presents as (Fig. 6.11):
(a) Hollow in rounded contour of the shoulder
(b) Prominence of shoulder tip
Frozen shoulder (adhesive capsulitis): It is a clinical
condition characterized by pain and uniform limitation of
all movements of the shoulder joint, though there are no
radiological changes in the joint. It occurs due to shrinkage
of the joint capsule, hence the name adhesive capsulitis.
This condition is generally seen in individuals with 4060
years of age.
Acromion process
scapula. The articular surfaces are covered with fibrocartilage.

The joint cavity is subdivided by an incomplete wedgeshaped articular disc.
Prominence of shoulder tip

Hollowing in shoulder contour
Upper end of humerus
Joint Capsule
It is thin, lax fibrous sac attached to the margins of articular
surfaces.
Glenoid cavity
Fig. 6.11 Dislocation of the shoulder joint. Note the

changes in the contour of shoulder.
Rotator cuff disorders: The rotator cuff disorders include

calcific supraspinatus tendinitis, subacromial the rotator
cuff represent overall the most common cause of shoulder
pain. The rotator cuff is commonly injured during repetitive
use of the upper limb above the horizontal level (e.g., in
throwing sports, swimming, and weight lifting). The
deposition of calcium in the supraspinatus tendon is
common. The calcium deposition irritates the overlying
subacromial bursa causing subacromial bursitis.
Consequently, when the arm is abducted the inflamed
bursa is caught between tendon and acromion
impingement, which causes severe pain. In most people,
pain occurs during 60120 of abduction (painful arc
syndrome). The rotator cuff disorders usually occur in
males after 50 years of age.
The pain due to subacromial bursitis is elicited when
the deltoid is pressed just below the acromion, when the
arm is adducted. The pain cannot be elicited by the
pressure on the same point when the arm is abducted
because the bursa slips/disappears under the acromion
process (Dawbarns sign).
Ligaments
These are acromioclavicular and coracoclavicular ligaments.
1. Acromioclavicular ligament: It is a fibrous band that
extends from acromion to the clavicle. It strengthens the
acromioclavicular joint superiorly.
2. Coracoclavicular ligament: It lies a little away from the
joint itself but play an important role in maintaining the
integrity of the joint.
The coracoclavicular ligament consists of two parts:
(a) conoid and (b) trapezoid, which are united posteriorly and often separated by a bursa.
The conoid ligament is an inverted cone-shaped
fibrous band. The apex is attached to the root of the
coracoid process just lateral to the scapular notch and
base is attached to the conoid tubercle on the inferior
surface of the clavicle.
The trapezoid ligament is a horizontal fibrous band
that stretches from upper surface of the coracoid
process to the trapezoid line on the inferior surface of
lateral end of the clavicle.
N.B. The coracoclavicular ligament is largely responsible
for suspending the weight of the scapula and upper limb
from clavicle.
The coracoclavicular ligament is the strongest ligament
of the upper limb.
Movements
The acromioclavicular joint permits the rotation of
acromion of scapula at the acromial end of the clavicle.
These movements are associated with movements of scapula
at the scapulothoracic joint/linkage.
ACROMIOCLAVICULAR JOINT (Fig. 6.12)

STERNOCLAVICULAR JOINT (Fig. 6.12)
Type
It is a plane type of the synovial joint between the lateral end
of the clavicle and acromion process of the scapula. The
acromioclavicular joint is located about 2.5 cm medial to the
point of the shoulder.
Type
The sternoclavicular joint is a saddle type of the synovial
joint.
Articular Surfaces
These are small facets present on the lateral end of clavicle
and the medial margin of the acromion process of the
Articular Surfaces
The rounded sternal end of clavicle articulates with the
shallow socket at the superolateral angle of the manubrium
sterni and adjacent part of the 1st costal cartilage. The medial
79
80
Acromioclavicular joint
Interclavicular ligament
Articular disc
Clavicle
Incomplete
articular disc
Acromion
Coracoclavicular
ligament
Trapezoid
part
Conoid
part
Coracoid
process
Costoclavicular
ligament
First costal
cartilage
Manubrium
sterni
First rib
Fig. 6.12 Sternoclavicular and acromioclavicular joints.
end of clavicle rises higher than the manubrium, hence it

poorly fits into its shallow socket. But a strong thick articular
disc of fibrocartilage attached superiorly to the clavicle and
1st costal cartilage inferiorly prevents the displacement of
the medial end of the clavicle.
The articular surface of clavicle is convex from above
downwards and slightly concave from front to back. The
articular surface of sternum is reciprocally curved. The
articular surfaces are covered with fibrocartilage.
Articular Capsule
The joint capsule is attached to the margins of the articular
surfaces including the periphery of the articular disc. The
synovial membrane lines the internal surface of the fibrous
joint capsule, extending to the edges of the articular disc.
Ligaments
1. Anterior and posterior sternoclavicular ligaments:
They reinforce the joint capsule anteriorly and
posteriorly. The posterior ligament is weaker than the
anterior ligament.
2. Interclavicular ligament: It is T-shaped and connects
the sternal ends of two clavicles and strengthens the
joint capsule superiorly. In between, it is attached to the
superior border of the suprasternal notch.
3. Costoclavicular ligament: It anchors the inferior surface
of the sternal end of clavicle to the first rib and adjoining
part of its cartilage.
Movements
The sternoclavicular joint allows the movements of pectoral
girdle. This joint is critical to the movement of the clavicle.
Dislocation of the sternoclavicular joint: It is rare
because the sternoclavicular (SC) joint is extremely
strong. However, dislocation of this joint in people
below 25 years of age may result from fractures
through the epiphyseal plate because epiphysis at the
sternal end of clavicle does not unite until 2325 years
of age. The medial end is usually dislocated anteriorly.
Backward dislocation is prevented by the costoclavicular ligament.
Transmission of weight of the upper limb: The
weight of the upper limb is transmitted from scapula to
the clavicle through coracoclavicular ligament, and
then from clavicle to sternum through sternoclavicular
joint. Some of the weight is transmitted to the first rib
through costoclavicular ligament (Fig. 1.4). When a
person falls on the outstretched hand the force of blow
is usually transmitted along the length of the clavicle,
i.e., along its long axis. The clavicle may fracture at the
junction of its middle and lateral third but it is rare for
the SC joint to dislocate.
Dislocation of the acromioclavicular joint: It may
occur following a severe blow on the superolateral part
of the shoulder. In severe form, both acromioclavicular
and coracoclavicular ligaments are torn. Consequently
the shoulder separates from the clavicle and falls
because of the weight of the limb. The acromioclavicular
joint dislocation is often termed shoulder separation.
SCAPULOTHORACIC ARTICULATION/LINKAGE
The scapulothoracic articulation is not a true articulation
but a functional linkage between the ventral aspect of the
scapula and lateral aspect of the thoracic wall. The linkage is

provided by serratus anterior muscle. The movements of
scapula around the chest wall are facilitated by the presence
of loose areolar tissue between the serratus anterior and
subscapularis muscles.
SCAPULOHUMERAL RHYTHM
Most of the movements at the shoulder involve the
movements of humerus and scapula simultaneously and
not successively.
According to older concept, abduction of shoulder up to

90 occurs at the glenohumeral/scapulohumeral joint and
beyond 90 the movement is essentially an upward rotation
of the scapula.
But recently it has been established beyond doubt by
fluoroscopic studies that there is rotation of scapula even from
the initial stages of abduction at the shoulder. Thus there is
rhythm between the scapular and humeral movements called
scapulo-humeral rhythm. In abduction, there is 1 of lateral
rotation of scapula for every 2 of movement at the scapulohumeral joint. The paralysis of muscles, which interferes with
this rhythm seriously affects the movements of the shoulder.
81
CHAPTER
Cutaneous Innervation,
Venous Drainage and
Lymphatic Drainage of
the Upper Limb
CUTANEOUS INNERVATION
The knowledge of cutaneous innervation is essential during
physical examination of the patient. The sensory testing of
skin of the upper limb is performed whenever a damage of
nerves arising from C3 to T2 spinal segments is suspected.
Light touch and pinprick are the main sensations tested
routinely, but the temperature, two-point discrimination,
and vibration are also tested in special cases. The area of
anesthesia and paresthesia are mapped out and matched
with the dermatomal distribution. In compression of nerve
roots of spinal nerves arising from C3 to T2 spinal segments
due to spondylitis, pain is referred to the respective
dermatomes.
CUTANEOUS NERVES OF THE UPPER LIMB

The cutaneous nerves of the upper limb are derived from
the ventral rami of spinal nerves derived from C3 to T2
spinal segments. These nerves are derived from the ventral
rami because the upper limb buds develop from ventral half
of the body opposite the C3T2 spinal segments. During
dissection, the cutaneous nerves are seen to arise from three
sources, viz.
1. Cervical plexus.
2. Brachial plexus.
3. Intercostobrachial nerve.
The cutaneous nerves carry sensations of pain, touch,
temperature, and pressure. In addition, they carry
sympathetic fibres, which supply sweat glands, dermal
arterioles, and arrector pili muscles. The effect of sympathetic
stimulation on skin, therefore, is sudomotor, vasomotor, and
pilomotor, respectively. The area of skin supplied by a single
spinal nerve/segment is termed dermatome. The cutaneous
nerves contain fibres from more than one spinal nerve and each
spinal nerve provides fibres to more than one cutaneous nerve.
As a result, skin areas supplied by the cutaneous nerves do not

correspond with dermatomes.
CUTANEOUS NERVES SUPPLYING DIFFERENT REGIONS

OF THE UPPER LIMB (Fig. 7.1)
These are as follows:
1. Pectoral region:
Above the 2nd rib, this region is supplied by the
supraclavicular nerves (C3, C4) and below the 2nd rib
by the intercostal nerves (T2T6).
2. Axilla:
The skin of the armpit is supplied by:
(a) intercostobrachial nerve (T2) and
(b) small branches from T3.
3. Shoulder:
(a) Upper half of the deltoid region is supplied by the
supraclavicular nerves (C3, C4).
(b) Lower half of the deltoid region is supplied by the
upper lateral cutaneous nerve of the arm, which is a
cutaneous branch of the axillary nerve.
4. Arm (brachium):
(a) Upper medial part of the arm is supplied by the
intercostobrachial nerve (T2) derived from 2nd
intercostal.
(b) Lower medial part of the arm is supplied by the
medial cutaneous nerve of the arm (T1, T2) from
medial cord of the brachial plexus.
(c) Upper lateral half of the arm is supplied by the
upper lateral cutaneous nerve of the arm from
axillary nerve.
(d) Lower lateral half of the arm is supplied by the lower
lateral cutaneous nerve of the arm (C5, C6) from
radial nerve.
(e) Posterior aspect of the arm is supplied by the
posterior cutaneous nerve of the arm (C5) from
radial nerve.
84
Supraclavicular
nerves (C3, C4)
Supraclavicular
nerve
T2
T2
T3
T3

nerve of arm

nerve of arm
Intercostobrachial
nerve
Lower lateral cutaneous

nerve of arm
Medial cutaneous
nerve of arm
Medial cutaneous
nerve of forearm
Lateral cutaneous
nerve of forearm
Posterior cutaneous
nerve of arm
Posterior cutaneous
nerve of forearm
Lateral cutaneous
nerve of forearm
Median nerve
(cutaneous branches)
Ulnar nerve
(cutaneous branches)
Dorsal branch of
ulnar nerve
radial nerve
Fig. 7.1 Cutaneous innervation of the upper limb.
FOREARM (ANTEBRACHIUM)
It is supplied by medial, lateral, and posterior cutaneous
nerves derived from the medial, lateral, and posterior cords
of the brachial plexus, respectively.
Medial side of the forearm is supplied by the medial

cutaneous nerve of the forearm (C8, T1) from the medial
cord of the brachial plexus. It becomes cutaneous halfway
down the arm along the basilic vein.
Lateral side of the forearm is supplied by the lateral
cutaneous nerve of the forearm (C5, C6) from
musculocutaneous nerve from the lateral cord of the
brachial plexus. It is the continuation of the
musculocutaneous nerve. It emerges at the lateral border of

the biceps and divides into anterior and posterior branches.
Posterior side of the forearm is supplied by the posterior
cutaneous nerve of the forearm (C6, C7, C8) from radial
nerve, a branch from the posterior cord of the brachial
plexus. It runs down the posterior aspect of forearm up to
the wrist.
HAND
1. Palm of the hand
(a) Lateral two-third of the palm is supplied by the
palmar cutaneous branch of the median nerve.
(b) Medial one-third of the palm is supplied by the

palmar cutaneous branch of the ulnar nerve.
2. Dorsum of the hand
(a) Lateral two-third of the dorsum of hand is supplied
by the superficial terminal branch of the radial
nerve (superficial radial nerve).
(b) Medial one-third of the dorsum of hand is supplied
by the dorsal branch/posterior cutaneous branch of
the ulnar nerve.
C3
C3
C4
C4
T2
T2
C5
C5
DIGITS
Ventral
axial line
1. Palmar aspects of the lateral 3 digits and their dorsal

aspects up to distal half of the middle phalanges are
supplied by the digital branches of median nerve.
2. Palmar aspects of the medial 1 digit and their dorsal
aspects up to distal half of the middle phalanges by the
palmar digital branches of the ulnar nerve.
3. Dorsal aspects of the lateral 3 digits up to proximal
half of their middle phalanges are supplied by the digital
branches of the radial nerve.
4. Dorsal aspects of the medial 1 digit up to their middle
phalanges are supplied by the digital branches of the
ulnar nerve.
Dorsal
axial line
T1
T1
C8
C8
C6
C6
C7
C7
Fig. 7.3 Dermatomes of the upper limb: A, anterior aspect;

B, dorsal aspect.
DERMATOMES OF THE UPPER LIMB

(Figs 7.2 and 7.3)
As already mentioned, the area of the skin supplied by a
single spinal nerve is called dermatome.
In the trunk, the arrangement of dermatomes is simple
(typical) because spinal nerves supplying it do not form
plexuses and are arranged segmentally. A typical dermatome
extends on the side of the trunk from the anterior median
line to the posterior median line.
Preaxial
border
C2
C3
C4
C2
C5
C6
C7
C6
C5
C4
C8
T1
T2
C3
C7
C8
T1
T3
T2
Postaxial
border
A
Fig. 7.2 Arrangement of dermatomes in the developing

upper limb: A, simple dermatomal pattern to begin with C5
supplying the preaxial strip and T1 the postaxial strip;
B, definitive dermatomal pattern of the upper limb bud.
In the limbs, the arrangement of dermatomes is

complicated because of the rotation of the limbs during their
development. It becomes further complicated because spinal
nerves supplying them form plexuses. (For details, see
Chapter 5 of Textbook of Clinical Neuroanatomy, 2e by
Vishram Singh.) During development, before rotation each
limb has preaxial and postaxial borders with former being
directed towards the head. The digits along the preaxial
border are thumb in the upper limb and big toe in the lower
limb. During rotation of the limbs, the upper limb rotates
laterally. As a result its preaxial border and thumb lie on the
lateral side. The lower limb rotates medially. Therefore, its
preaxial border and big toe lie on the medial side.
Consequently the dermatomes are arranged consecutively
downwards on the lateral side of the upper limb and upwards
on the medial side of the upper limb.
To be very precise, the dermatomes of the upper limb are
arranged in a numerical sequence as follows:
1. From the shoulder to the thumb, along the preaxial
border by C3C6 spinal segments.
2. From the thumb to the little finger by C6C8 spinal
segments.
3. From the little finger to the axilla along the postaxial
border by C8T2 spinal segments.
The segmental innervation is summarized in Table 7.1.
85
86
Table 7.1 Segmental innervations of the upper limb

Area
Segment
Nipple
T4
Tip of the shoulder
C4
Lateral side of the arm
C5
Lateral side of the forearm
C6
Thumb
C6
Hand middle 3 digits
C7
Little finger
C8
Medial side of the forearm
C8
Medial side of the arm
T1
Axilla
T2
As discussed in the beginning, the understanding of
dermatomal arrangement is clinically important because the
physicians commonly test the integrity of spinal cord
segments from C3 to T2 by performing the sensory
examination for touch, pain, and temperature. This is so
because the sensory loss of the skin following injuries to the
cord conforms to the dermatome.
N.B. The students must remember that there is varying

degrees of overlapping of adjacent dermatomes.
Consequently the area of sensory loss following damage to
the cord segments is always less than the area of distribution
of the dermatomes.
VENOUS DRAINAGE OF THE UPPER LIMB

The veins draining the upper limb, as elsewhere in the body,
are divided into two sets/groups (a) superficial and (b) deep.
The superficial veins are located in the superficial fascia
and are easily accessible. Being easily accessible, they are
frequently used by the clinicians for drawing blood samples
or for giving intravenous injections.
The deep veins lie deep to muscles and accompany arteries
as venae comitantes.
SUPERFICIAL VEINS
Superficial veins have the following general features:
1. The superficial veins lie in the superficial fascia.
2. The superficial veins have a tendency to run away form
the pressure sites, hence they are absent in the palm,
along the ulnar border of the forearm, and back of the

elbow.
3. There are two major superficial veins, one along the
preaxial border and the other along the postaxial
border of the limb. The preaxial vein (cephalic vein) is
longer than the postaxial vein (basilic vein), but the
postaxial basilic vein drains more efficiently. The load
of long cephalic vein is greatly relieved as a good
amount of its blood is transferred to the efficient basilic
vein by the median cubital vein (communicate
channel).
The superficial veins are accompanied by the cutaneous
nerves and superficial lymphatics.
Superficial veins comprise:
1.
2.
3.
4.
Dorsal venous arch

Cephalic vein
Basilic vein
Median cubital vein
Dorsal venous arch (Fig. 7.4): The dorsal venous arch is a

network of veins on the dorsum of hand. It presents irregular
arrangement of veins usually with its transverse element,
which lies 23 cm proximal to the heads of metatarsals.
Tributaries
The tributaries of dorsal venous arch are:
1.
2.
3.
4.
5.
Three dorsal metacarpal veins.

A dorsal digital vein from the medial side of little finger.
A dorsal digital vein from the lateral side of index finger.
Two dorsal digital veins of the thumb.
Veins draining palm of hand. These are (a) veins that
pass around the margins of the hand and (b) perforating
veins, which pass dorsally through the interosseous
spaces.
The dorsal venous arch drains into cephalic and basilic

veinsthe efferent vessels of dorsal venous arch.
N.B. The pressure on the palm during gripping does not
hamper the venous return of the palm, rather it facilities the
return because venous blood from the palm is drained into
dorsal venous arch.
Cephalic vein (Figs 7.4 and 7.5): The cephalic vein begins as
the continuation of lateral end of the dorsal venous arch.
It crosses the roof of anatomical box, ascends on the
radial border of the forearm, continues upwards in front of
elbow along the lateral border of biceps, pierces the deep
fascia at the lower border of the pectoralis major, runs in
cleft between the deltoid and pectoralis major (deltopectoral
groove) up to the infraclavicular fossa, where it pierces the
clavipectoral fascia and drains into the axillary vein.
Axillary vein
Median cubital
vein
Lateral cutaneous
nerve of forearm
Basilic vein
Cephalic vein
Medial cutaneous
nerve of forearm
Median vein
of forearm
Basilic vein
Cephalic vein
Dorsal venous arch
Dorsal digital vein
from medial side of
little finger
Dorsal digital
veins of thumb
Three dorsal
metacarpal veins
Fig. 7.4 Dorsal venous arch and initial parts of the courses
of cephalic and basilic veins.
Fig. 7.5 Cephalic and basilic veins.
N.B.
At elbow, greater amount of blood from the cephalic vein
is shunted into the basilic vein through median cubital
vein.
Cephalic vein is accompanied by the lateral cutaneous
nerve of the forearm.
An accessory cephalic vein from back of the forearm
(occasional) ends in the cephalic vein below the elbow.
Cephalic vein is the preaxial vein of the upper limb and
corresponds to the great saphenous vein of the lower
limb.
N.B.
Basilic vein (Figs 7.4 and 7.5): The basilic vein begins as the
continuation of the medial end of the dorsal venous arch of
the hand. It runs upwards along the back of the medial
border of the forearm, winds round this border near the
elbow to reach the anterior aspect of the forearm, where it
continues upwards in front of the elbow along the medial
side of the biceps brachii up to the middle of the arm, where
it pierces deep fascia, unites with the brachial veins and runs
along the medial side of the brachial artery to become
continuous with the axillary vein at the lower border of the
teres major.
Basilic vein is the postaxial vein of the upper limb and

corresponds to the short saphenous vein of the lower limb.
About 2.5cm above the medial epicondyle of humerus,
it is joined by the median cubital vein.
It is accompanied by the medial cutaneous nerve of the
forearm.
Median cubital vein (Fig. 7.5): It is a communicating venous

channel between the cephalic and basilic veins, which shunts
blood from the cephalic vein to the basilic vein.
It begins from the cephalic vein, 2.5 cm below the elbow
bend, runs obliquely upwards and medially to end in the
basilic vein, 2.5 cm above the bend of elbow.
The important features of median cubital vein are as
follows:

It is separated from brachial artery by the bicipital

aponeurosis.
It communicates with the deep veins through a perforator
vein, which pierces the bicipital aponeurosis.
It receives median vein of the forearm.
It shunts blood from cephalic vein to the basilic vein.
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Median vein of the forearm

Median vein of the forearm begins from palmar venous
network, runs upwards in the midline on the anterior aspect
of forearm to end in any one of three veins in front of elbow
(viz. cephalic, basilic, and median cubital veins).
N.B. Sometimes the upper end of median vein of the
forearm bifurcates into median cephalic and median basilic
veins, which join the cephalic and basilic veins, respectively.
In this situation, the median cubital vein is absent (Fig. 7.6B).
Common venous patterns in front of the elbow (Fig. 7.6)

The veins in front of the elbow commonly form two patterns,
viz.
1. H-shaped pattern.
2. M-shaped pattern.
Venepuncture in the cubital fossa: The veins in front of
the elbow, e.g., median cubital vein, cephalic vein, and
basilic vein are routinely used for giving intravenous
injections and for withdrawing blood from the donors. The
median cubital vein is most preferred due to the following
reasons:
(a) It is the most superficial vein in the body, hence
access is easy.
(b) It is well supported by the underlying bicipital
aponeurosis.
(c) It is well anchored to the deep vein by a perforating
vein, hence it does not slip during procedure.
The cephalic vein is preferred for hemodialysis in the
patients with chronic renal failure (CRF), to remove waste
products from blood.
The cut-down of cephalic vein in the deltopectoral groove
is preferred when the superior vena cava infusion is
necessary.
The basilic vein is preferred for cardiac catheterization for
the following reasons:
(a) The diameter of basilic vein increases as it ascends
from cubital fossa to the axillary vein.
(b) It is in direct line with the axillary vein. To enter the
right atrium the catheter passes in succession as
follows:
Basilic vein axillary vein subclavian vein
brachiocephalic vein superior vena cava right atrium
of the heart.
The cephalic vein is not preferred for cardiac
catheterization due to the following reasons:
(a) Its diameter does not increase as it ascends.
(b) It joins the axillary vein at a right angle hence it is
difficult to maneuver the catheter around sharp
cephaloaxillary angle.
(c) In deltopectoral groove, it frequently divides into small
branches. One of these branches ascends over the
clavicle and joins the external jugular vein.
Cephalic
vein
Basilic
vein
Median
vein of
forearm
Basilic
vein
Cephalic
vein
Median
vein of
forearm
Fig. 7.6 Common venous patterns in front of the elbow:

A, H-shaped pattern; B, M-shaped pattern.
DEEP VEINS
The deep veins comprise:
(a) venae comitantes, which accompany the large arteries,
such as radial, ulnar, and brachial arteries,
(b) venae comitantes of the brachial artery, and
(c) axillary vein.
Venae comitantes of the radial and ulnar arteries
accompany the radial and ulnar arteries, respectively, and
join to form the brachial veins.
Venae comitantes are small veins, one on each side of the
brachial artery. They join axillary vein at the lower border of
the teres major muscle. The medial one often joins the basilic
vein.
Axillary vein begins as a continuation of basilic vein at the
lower border of the teres major muscle and runs through
axilla, passes through its apex to continue as subclavian vein
at the outer border of the first rib (for details see Chapter 4,
page 52).
LYMPHATIC DRAINAGE OF THE

UPPER LIMB (Fig. 7.7)
The lymphatic drainage of the upper limb follows the
unnamed lymph vessels, which originate in the hand and
run upwards towards the axilla. When they reach cubital
fossa, the lymph passes through cubital nodes. From here
lymph vessels run superiorly to drain into the axillary lymph
nodes.
LYMPH VESSELS
The lymph vessels draining the lymph from the upper limb,
as elsewhere in the body, are divided into two groups:
superficial and deep.
Infraclavicular
lymph nodes
Deltopectoral
node
Lateral group of
axillary lymph nodes
Supratrochlear/
epitrochlear node
Those from medial side of the limb and medial three digits
follow the basilic vein and drain into the lateral group of
axillary nodes.
Some of the medial lymph vessels terminate in the
supratrochlear or epitrochlear nodes, which are situated just
above the medial epicondyle along the basilic vein.
A few lymph vessels drain the thumb end in the
deltopectoral lymph nodes. The efferents from these nodes
pierce the clavipectoral fascia to drain in the apical group of
axillary nodes.
N.B.
Almost all the superficial lymph vessels of the upper limb
drain into lateral group of axillary nodes.
Lymph from palm is drained into the lymph plexus on the
dorsum of the hand.
Vertical area of lymph shed is in the middle of the back
of arm and forearm: The lymph vessels from the back of
the arm and forearm curve around the medial and lateral
borders of limb to reach the front of the limb, thus
forming a vertical area of lymph shed.
DEEP LYMPH VESSELS

The deep lymph vessels are much less numerous than the
superficial lymph vessels. They drain structures lying deep to
deep fascia, viz. muscles. The deep lymph vessels course
along the arteries and drain into the lateral group of the
axillary lymph nodes.
Fig. 7.7 Lymphatic drainage of the upper limb.
SUPERFICIAL LYMPH VESSELS

The superficial lymph vessels are located in the
subcutaneous tissue. They are much more numerous than
the deep lymph vessels. They generally accompany the
superficial veins.
The superficial lymph vessels drain the lymph from skin
and subcutaneous tissue. They course upwards towards the
axilla. Most of them end in the axillary lymph nodes.
Those from lateral side of the limb and lateral two digits
follow the cephalic vein and drain into the infraclavicular
lymph nodes.
Lymphangitis: The inflammation of the lymph vessels is

termed lymphangitis. It usually follows trivial injuries, e.g.,
cuts and pin-pricks, to any part of the upper limb. In acute
lymphangitis, the lymph vessels may be seen underneath
the skin as red streaks, which are tender (i.e., painful to
touch).
Lymphedema: The obstruction of lymph vessels may
cause edema (i.e., swelling) in the area of drainage due to
accumulation of tissue fluid.
LYMPH NODES
The lymph nodes draining the upper limb are divided into
two groups: (a) superficial and (b) deep.
SUPERFICIAL LYMPH NODES

They lie in the superficial fascia, along the superficial vein.
These are as follows:
1. Infraclavicular nodes, one or two in number, lie on the
clavipectoral fascia along the cephalic vein. They drain
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lymph from thumb including its web and upper part of

the breast.
2. Deltopectoral node, lie in the deltopectoral groove
along the cephalic vein just before it pierces the deep
fascia. It is thought to be displaced infraclavicular node.
It drains the lymph from the breast and adjoining small
structures.
3. Superficial cubital/supratrochlear nodes lie 5 cm above
the medial epicondyle along the basilic vein. They
drain the lymph from the ulnar side of the hand and
forearm.
DEEP LYMPH NODES

The deep lymph nodes are as follows:
1. Axillary lymph nodes are present in the axilla and are

divided into four sets. These are main lymph nodes of
the upper limb (for details see Chapter 4, page 53).
2. A few other deep lymph nodes lie on the following sites:
(a) Along the medial side of the brachial artery.
(b) In the cubital fossa, at the bifurcation of the brachial
artery (called deep cubital node).
(c) Occasionally along the arteries of the forearm.
The axillary lymph nodes are enlarged (lymphadenopathy)
and become painful following infection in any part of the
upper limb.
In infection affecting the medial side of the hand and forearm,
supratrochlear lymph node become enlarged and tender.
CHAPTER
Arm
The arm is the part of the upper limb between shoulder

and elbow. The bone of the armthe humerus articulates
above with scapula to form shoulder joint and below with
radius and ulna to form elbow joint. The humerus is almost
entirely covered by muscles. The primary neurovascular
bundle of the arm is located on the medial side of the arm,
hence protected by the limb, which it serves. It consists of
brachial artery, the basilic vein, and median, ulnar, and
radial nerves.
SURFACE LANDMARKS
The following bony landmarks and soft tissue structures can
be felt in the living individual:
1. Greater tubercle of the humeruscan be felt just below
and lateral to the acromion, deep to deltoid with arm
lying by the side of the trunk. It forms the most lateral
bony point of the shoulder region.
2. Shaft of the humeruscan be felt indistinctly in thin
individuals.
3. Medial epicondyle of the humerusis the prominent
bony projection felt on the medial side of the elbow. The
projection is best seen and felt in midflexed elbow.
4. Lateral epicondyle of the humeruscan be felt in the
upper part of the depression on the posterolateral aspect
of the extended elbow.
5. Medial and lateral supracondylar ridgescan be felt in
the lower one-fourth of the arm as the upward
continuations of medial and lateral epicondyles,
respectively.
6. Deltoid muscleforms the rounded contour of the
shoulder, which becomes prominent on abducting the
arm. It covers the upper half of the humerus anteriorly,
laterally, and posteriorly and its apex (i.e., tendon) is
attached to the lateral side of the middle of humerus on
deltoid tuberosity.
7. Biceps muscleforms a conspicuous bulge on the front

of arm, which becomes prominent on flexing the elbow.
Its tendon can be felt on the front of the elbow.
8. Brachial artery pulsationscan be felt in front of the
elbow just medial to the tendon of biceps muscle.
9. Ulnar nervecan be rolled by the middle finger in the
groove behind the medial epicondyle of the humerus.
10. The superficial veins in front of elbow (i.e., cephalic,
basilic, and median cubital veins)become visible when
they are distended by applying tight pressure around the
arm and then flexing and extending the elbow a few times
with clenched fist.
11. Head of radiuscan be felt in the depression on the
posterolateral aspect of the elbow just distal to the lateral
epicondyle. The rotation of the head of radius can be felt
by supinating and pronating the forearm.
12. Olecranon process of ulna (proximal part of ulna)is
readily palpable on the back elbow between the medial
and the lateral epicondyles.
COMPARTMENTS OF THE ARM (Fig. 8.1)

The deep fascia encloses the arm like a sleeve. The two fascial
septa, one on the medial side and one on the lateral side
extend inwards from the fascial sleeve and get attached to the
medial and lateral supracondylar ridges of the humerus,
respectively. These septa and fascial sleeve divide the arm
into anterior and posterior compartments. Each
compartment has its own muscles, nerve, and artery.
N.B. Some structures, however, pierce the intermuscular
septa to shift from one compartment to the other, viz.
Ulnar nerve and superior ulnar collateral artery pierce the
medial intermuscular septum to enter the posterior
compartment.
Radial nerve and radial collateral artery pierce the lateral
intermuscular septum to enter the anterior compartment.
Arm
Brachial artery
Median nerve
Biceps brachii
Basilic vein
Cephalic vein
Ulnar nerve
Skin
Superficial fascia
Med. intermuscular
septum
Brachialis
H
Deep fascia
Radial nerve
Profunda
brachii artery
Lateral head
Medial head
of triceps brachii
Long head
Fig. 8.1 Transverse section of the arm just below the level of insertion of deltoid muscle (H = humerus).
CONTENTS OF THE ANTERIOR COMPARTMENT

OF THE ARM

Muscles: Biceps brachii, coracobrachialis, and brachialis.

Nerve: Musculocutaneous nerve.
Artery: Brachial artery.
In addition to the above structures, the following large nerves

also pass through the anterior compartment of arm:

Median nerve.
Ulnar nerve.
Radial nerve.
Muscles
Biceps Brachii (Fig. 8.2)
Origin
The biceps brachii muscle arises from scapula by two heads:
long and short:
1. Long head arises from supraglenoid tubercle within the
capsule of shoulder joint. Its tendon runs above the head
of humerus and emerges from the joint through
intertubercular sulcus.
2. Short head arises along with coracobrachialis from the tip
of the coracoid process.
The two heads join together in the distal third of the arm to
form a belly that ends in a tendon, which gives off the bicipital
aponeurosis from its medial aspect, opposite the bend of

elbow.
Insertion
The biceps muscle is inserted into:
(a) the posterior part of the radial tuberosity by its tendon.
A bursa intervenes between the tendon and anterior part
of the tuberosity, and
(b) the deep fascia on the medial aspect of forearm by its
aponeurosis (bicipital aponeurosis). The aponeurosis
protects the underlying brachial artery and median
nerve.
Nerve supply
By musculocutaneous nerve (C5, C6, and C7).
Actions
1. It is strong supinator of the forearm, when elbow is
flexed. This action is used in screwing movements such
as tightening the screw with screw driver.
2. It is a powerful flexor of the forearm, when elbow is
extended.
3. It is also a weak flexor of the shoulder joint.
Clinical testing
The biceps brachii is tested by asking the patient to flex the
elbow against resistance when the forearm is supinated. In
this act, the muscle forms a prominent bulge on the front of
the arm.
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Origin
1. Short head from tip of
coracoid process
Origin
Tip of coracoid
process in common
with the short head of
biceps brachii
2. Long head from

supraglenoid
tubercle of scapula
Short head of
biceps brachii
CORACOBRACHIALIS
Insertion
Middle (5 cm) of the
medial border of
humerus
BICEPS BRACHII
Tendon of
biceps
Bicipital
aponeurosis
Insertion
Posterior part of
radial tuberosity
Fig. 8.3 Origin and insertion of the coracobrachialis.
Nerve supply
Fig. 8.2 Origin and insertion of the biceps brachii.
Biceps reflex: It is tested during physical examination by
tapping the tendon of biceps brachii by reflex hammer with
forearm pronated and partially extended at elbow. The
normal reflex is brief jerk-like flexion of the elbow. The
normal reflex confirms the integrity of musculocutaneous
nerve and C5 and C6 spinal segments.
Coracobrachialis (Fig. 8.3)

Origin
From the tip of coracoid process of the scapula along with
short head of the biceps brachii.
Insertion
Into the middle of the medial border of the shaft of the
humerus.
By musculocutaneous nerve.
Actions
It is a weak flexor and adductor of the arm.
N.B.
Morphology of the coracobrachialis: It represents the
muscle of medial compartment of the forelimb of
quadrupeds, which is not well-developed in human
beings. In some animals, this muscle consists of three
heads. In human beings, the upper two heads are fused
and musculocutaneous nerve passes between the two
fused heads. The lower third head has disappeared in
humans. But, occasionally the lower head persists as a
fibrous band (ligament of Struthers), which extends
between supratrochlear/trochlear spur and medial
epicondyle of the humerus (Fig. 2.10). The median nerve
and brachial artery then pass deep to the ligament and
may be compressed.
Arm
N.B. The brachial artery is superficial throughout its course,

being covered only by the skin and fasciae, hence easily
accessible.
Axillary artery
Teres major
muscle
Deltoid/ascending
branch
(anastomotic
branch)
Nutrient artery
Muscular branch
Posterior
descending branch
(radial collateral artery)
Branches
Profunda
brachii artery
Brachial artery
Superior ulnar
collateral artery
Inferior ulnar
collateral artery
Anterior
descending branch
(middle collateral artery)
Neck of radius
Radial artery
(small terminal branch)
1. Muscular branches to the muscles of the anterior

compartment of the arm.
2. Profunda brachii artery (largest and first branch). It
arises from the posteromedial aspect of the brachial
artery just below the lower border of the teres major. It
accompanies the radial nerve with which it immediately
leaves the lower triangular intermuscular space to enter
the spiral groove on the posterior surface of the
humerus.
3. Nutrient artery to humerus enters the nutrient foramen
of humerus located near the insertion of coracobrachialis.
4. Superior ulnar collateral artery arises near the middle
of the arm and accompanies the ulnar nerve.
5. Inferior ulnar collateral (or supratrochlear artery)
arises near the lower end of humerus and divides into
the anterior and posterior branches, which take part in
the formation of arterial anastomosis around the
elbow.
6. Radial and ulnar arteries (terminal branches).
Ulnar artery
(large terminal branch)
Fig. 8.7 Brachial artery.
Brachial pulse: The brachial pulse is commonly felt in

the cubital fossa medial to the tendon of biceps and its
pulsations are auscultated for recording the blood
pressure. The biceps tendon is easily palpable on flexing
the elbow.
the level of neck of radius by dividing into radial and ulnar

arteries.
Relations
Anteriorly
Posteriorly
Medially
Laterally
In the upper part, it is related to medial

cutaneous nerve of the forearm, which lies in
front of it.
In the middle part, it is crossed by the median
nerve from lateral to medial side.
In the lower part, in the cubital fossa, it is
crossed by the bicipital aponeurosis.
From above downwards, the brachial artery lies
successively on long head of triceps, medial
head of triceps, coracobrachialis, and brachialis
muscles.
The ulnar nerve and basilic vein in the upper
part of the arm; and median nerve in the lower
part of the arm.
The median nerve, coracobrachialis, and biceps
in the upper part of arm and tendon of biceps
in the lower part.
Axillary artery
Humerus
Teres major
Brachial artery
Insertion of
coracobrachialis
Radial artery
Site of compression of
brachial artery
Ulnar artery
Fig. 8.8 Compression of the brachial artery against humerus.
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For easy remembering, the anastomosis is divided into the

following parts:
Brachial artery
Humerus
Supracondylar
fracture of humerus
Rupture of
brachial artery
Ulna
Fig. 8.9 Rupture of the brachial artery in supracondylar

fracture of the humerus.
Compression of brachial artery: The brachial artery can

be effectively compressed against the shaft of humerus at
the level of insertion of coracobrachialis to stop the
hemorrhages in the upper limb occurring from any artery
distal to the brachial artery, e.g., bleeding wounds of the
palmar arterial arches (Fig. 8.8).
Rupture of the brachial artery in supracondylar
fracture of the humerus may lead to Volkmanns ischemic
contracture (Fig. 8.9). For details see Chapter 9, p. 114.
Arterial Anastomosis around the Elbow (Fig. 8.10)

The arterial anastomosis around the elbow takes place
between the branches of brachial artery and those from the
upper ends of radial and ulnar arteries.
Brachial
artery
Profunda brachii
artery
Posterior
descending
branch
Superior ulnar
collateral
Arteries
Anterior
descending
branch
Inferior ulnar
collateral
L
Radial
recurrent
artery
Posterior
ulnar recurrent
Arteries
Anterior ulnar
recurrent
Interosseous
recurrent
artery
Common
interosseous artery
Ulnar artery
Radial
artery
Posterior
interosseous artery
Anterior
interosseous artery
Fig. 8.10 Arterial anastomosis around the elbow joint

(L lateral epicondyle, M medial epicondyle).
1. In front of the medial epicondyle:

(a) Inferior ulnar collateral artery and branch from the
superior ulnar collateral artery (branches of the
brachial artery), anastomose with
(b) Anterior ulnar recurrent artery (branch of the ulnar
artery).
2. Behind the medial epicondyle:
(a) Superior ulnar collateral artery and a branch from
the inferior ulnar collateral artery (branches of
brachial artery), anastomose with
(b) Posterior ulnar recurrent artery (branch of the ulnar
artery).
3. In front of lateral epicondyle:
(a) Radial collateral artery (branch of the profunda
brachii artery), anastomose with
(b) Radial recurrent artery (branch of the radial artery).
4. Behind the lateral epicondyle:
(a) Posterior descending artery (branch of the profunda
(b) Interosseous recurrent artery (branch of the posterior
interosseous artery); and a branch of common
interosseous artery (a branch of the ulnar artery).
5. Above the olecranon fossa:
(a) Middle collateral artery (branch of the profunda
(b) Transverse branch from the posterior division of the
inferior ulnar collateral artery.
Large Nerves Passing Through the Arm

These are median, ulnar, and radial nerves:
Median Nerve
The median nerve arises from the lateral and medial cords
of the brachial plexus in axilla. It is closely related to the
brachial artery throughout its course in the arm. Therefore,
it is like the brachial artery, it is superficially located except
at elbow where it is crossed by the bicipital aponeurosis.
The relationship of median nerve with the brachial artery
in the arm is as under (Fig. 8.11):
1. In the upper part, it is lateral to the artery.
2. In the middle part, it crosses in front of the artery from
lateral to medial side.
3. In the lower part, it is medial to the artery up to elbow.
Branches
In the arm, the median nerve gives rise to the following
branches:
1. Nerve to pronator teres just above the elbow.
2. Vasomotor nerve to the brachial artery.
3. Articular branch to the elbow joint at or just below the
elbow.
Arm
Radial nerve
Teres major
Median nerve
Ulnar nerve
Nerve to long
head of triceps
Long head
of triceps
Lateral head of
triceps
Nerve to lateral
head of triceps
Brachial artery
Posterior cutaneous
nerve of arm
Nerves to medial
head of triceps
Radial nerve
Lateral intermuscular
septum
Medial intermuscular
septum

nerve of arm
Nerves to anconeus
Ulnar nerve
Posterior cutaneous
nerve of forearm
Anconeus
Bicipital aponeurosis
Radial artery
Ulnar artery
Fig. 8.12 Course, relations, and branches of the radial

nerve in the arm.
Fig. 8.11 Relations of the median nerve with the brachial
artery in arm. The course of the radial and ulnar nerves in
the arm is also shown.
Ulnar Nerve
The ulnar nerve arises from medial cord of the brachial
plexus in the axilla. It then runs downwards on the medial
side of the arm medial to the brachial artery up to the
insertion of coracobrachialis. Here it pierces the medial
intermuscular septum along with the superior ulnar
collateral artery to enter the posterior compartment of the
arm. At the elbow, the ulnar nerve passes behind the medial
epicondyle of humerus where it can be easily palpated. The
ulnar nerve does not give any branch in the arm.
Radial Nerve (Fig. 8.12)
Origin and course
The radial nerve arises from the posterior cord of the brachial
plexus in the axilla. In the arm the nerve first lies posterior to
the brachial artery. Then it winds around the back of the arm to
enter the radial/spiral groove of humerus between the lateral
and medial heads of the triceps; where it is accompanied by
profunda brachii artery. At the lower end of the spiral groove,
it pierces lateral intermuscular septum and enters the
anterior compartment of the arm. Here it continues

downward in front of the elbow in the cubital fossa, between
the brachialis and brachioradialis muscles. Then at a variable
point it divides into two terminal branches: (a) a sensory
branch, the superficial radial nerve, and (b) a motor branch,
the deep radial nerve. The latter disappears into the substance
of supinator muscle just below the elbow.
Branches
1. In the axilla:
(a) Nerves to long and medial heads of triceps.
(b) Posterior cutaneous nerve of the arm.
2. In the spiral groove:
(a) Nerves to lateral and medial heads of triceps.
(b) Nerve to anconeus.
(c) Lower lateral cutaneous nerve of the arm.
(d) Posterior cutaneous nerve of forearm.
3. In the anterior compartment of the arm:
(a) Nerves to brachialis, brachioradialis, and extensor
carpi radialis longus.
(b) Articular branches to the elbow joint.
(c) Deep radial nerve.
(d) Superficial radial nerve.
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100
Contents of cubital fossa

(From medial to lateral side)
Origin of
brachioradialis
1. Median nerve
2. Brachial artery
Base of
cubital fossa
3. Tendon of biceps
4. Radial nerve
(superficial branch)
Common flexor origin
Brachioradialis
Pronator teres
Fig. 8.13 Boundaries and contents of the cubital fossa.
CUBITAL FOSSA (Fig. 8.13)

The cubital fossa is a triangular hollow in front of the elbow.
It corresponds (i.e., homologous) to the popliteal fossa of the
lower limb.
Boundaries
Lateral: Medial border of brachioradialis muscle.
Medial: Lateral border of pronator teres muscle.

Base:
Apex:
Floor:
Roof:
An imaginary horizontal line, joining the front of

two epicondyles of the humerus.
Meeting point of the lateral and medial boundaries.
Here brachioradialis overlaps the pronator teres.
It is formed by two muscles, brachialis in the upper
part and supinator in the lower part (Fig. 8.14).
It is formed from superficial to deep by (Fig. 8.15):
Brachialis
Supinator
Radial
tuberosity
Brachialis
Supinator
Radius
Fig. 8.14 Muscles forming the floor of cubital fossa: A, anterior view; B, cross-sectional view.
Ulna
102

Profunda brachii
artery and radial
nerve
Nerve to long head arises from the radial nerve in axilla.

Nerve to lateral head arises from the radial nerve in the
radial groove.
Nerve to medial head arises from the radial nerve in the
radial groove.
Actions
Origin of lateral
head from:
Oblique ridge on
the posterior aspect
of humerus
The triceps brachii is the powerful extensor of the elbow

joint. The long head supports the head of humerus during
hyperabduction of the arm.
Origin of long head from:
of scapula
TRICEPS
Injury of radial nerve in radial groove: If the radial nerve

is damaged in the radial groove, the extension of elbow and
triceps reflex is not lost because nerve to long head arises
from the radial nerve in axilla.
Origin of medial
head from:
Posterior surface
of humerus below
the radial groove
Insertion
Posterior part
of the superior
surface of the
olecranon process
Radial Nerve
It is described on page 99.
Profunda Brachii Artery (Deep Artery of the
Arm, Fig. 8.17)
The profunda brachii artery is the largest branch of the
brachial artery. It arises from the posterolateral aspect of the
brachial artery just below the teres major. It accompanies the
radial nerve through the radial groove and then terminates
by dividing into anterior and posterior descending branches,
which take part in the arterial anastomosis around the elbow
joint.
Teres major
Brachial artery
Fig. 8.16 Origin and insertion of the triceps brachii.

Deltoid branch
Insertion
The common tendon is inserted into the posterior part of
the superior surface of the olecranon process of ulna.
Profunda brachii
artery
Nutrient branch
to humerus
Muscular branches
N.B. A few fibres of deep head are inserted into the

posterior aspect of the capsule of elbow joint and are
referred to as articularis cubiti or subanconeus muscle.
These fibres prevent the nipping of the capsule during
extension of the arm.
Nerve supply
By radial nerve (C7, C8). Each head receives a separate
branch from radial nerve in the following manner:
Ant. descending branch

(radial collateral artery)
Radial
recurrent artery
Post. descending branch

(middle collateral artery)
Interosseous recurrent artery
Fig. 8.17 Branches of the profunda brachii artery.
Arm
Branches
1. Deltoid (ascending) branch: It ascends between long and
lateral heads of triceps and anastomoses with the descending branch of the posterior circumflex humeral artery.
2. Nutrient artery to humerus: It enters the shaft of humerus
in the radial groove, just behind the deltoid tuberosity.
3. Anterior descending (radial collateral) artery: It is
the smaller terminal branch, which accompanies the
radial nerve and anastomoses with the radial recurrent

artery in front of the lateral epicondyle of the
humerus.
4. Posterior descending (middle collateral) artery: It is
the larger terminal branch of the profunda brachii
artery, which descends behind the shaft of humerus
and anastomoses with the interosseous recurrent artery
behind the lateral epicondyle of the humerus.
103
104

" Most lateral bony point of the shoulder region
Greater tubercle of the humerus
" Workhorse of the forearm flexion
Brachialis muscle
" Most felt arterial pulse for recording blood

pressure
Brachial pulse in the cubital fossa
" Best place to compress the brachial artery to stop

hemorrhage in the arm and hand
Medial aspect of humerus near the middle of arm

(site of insertion of coracobrachialis)
" Largest branch of the brachial artery
" Neurovascular structures jeopardized in midshaft

fracture of the humerus
Radial nerve and profunda brachii artery
" Most preferred vein for venepuncture in the upper

limb
Median cubital vein
" Damage of the radial nerve in spiral groove

causes only weakness in extension of elbow and
not the total inability to extend elbow
Because branches of the radial nerve supplying

long and medial heads of triceps arise in axilla, i.e.,
above radial groove
" Ligament of Struthers
Fibrous band extending between the supratrochlear

spur and medial epicondyle of humerus
" Workhorse of the forearm extension
Medial head of triceps
Clinical Case Study

A 45-year-old weight lifter while lifting the heavy
weight in weight lifting competition suddenly felt a
sudden snap and severe pain in his shoulder region. He
dropped the weight and left the platform. He was taken
to the hospital for check up. On examination the doctor
noticed a ball-like bulge near the centre of the distal
part of the anterior aspect of the arm. The patient was
not able to supinate his arm and his forearm was
pronated and flexed. A diagnosis of rupture of tendon
of long head of biceps was made.
Questions
1. What are the causes of rupture of tendon of long
head of biceps and which age group does it mostly
affect?
2. What is origin of long and short heads of the biceps
brachii?
3. What caused the ball-like bulge in the front of the

arm and name this deformity?
Answers
1. (a) Rupture of tendon long head of biceps usually
occurs from wear and tear of an inflamed tendon
as it moves back and forth in the bicipital groove
of the humerus. It may also result from forceful
flexion of arm against excessive resistance as
during weight lifting.
(b) It usually occurs in individuals >35 years of
age.
2. (a) Long head from the supraglenoid tubercle of
the scapula.
(b) Short head from the tip of coracoid process of
the scapula.
3. (a) Detached belly of the biceps muscle.
(b) Popeye deformity.
CHAPTER
Forearm
The forearm extends from the elbow to the wrist and

contains two bones, which are tied together by the thin
strong fibrous membranethe interosseous membrane. The
head of radius is at the proximal end of the forearm whereas
the head of ulna is at the distal end of the forearm. The radius
and ulna at both their ends articulate with each other to
form the superior and inferior radio-ulnar joints. All
important movements of supination and pronation of the
forearm occur at these joints. The upper ends of radius and
ulna articulate with the lower end of humerus to form elbow
joint. The main purpose of the movements of the forearm at
elbow and radio-ulnar joints is to place the hand at the desired
place. The muscles, nerves, and vessels are present both on
the front and back of the forearm.
Surface Landmarks
A. On the Front of Forearm
1. Medial and lateral epicondyles of the humerus can be
easily felt at the elbow; the medial epicondyle is more
prominent than the lateral epicondyle. The ulnar nerve
can be rolled behind the medial epicondyle (also see
page 93).
2. Tendon of biceps brachii can be easily palpated in front
of the elbow. The pulsations of the brachial artery can be
felt just medial to the tendon.
3. Head of radius and olecranon process of the ulna have
been described on page 97.
3. Styloid processes of the radius and ulna can be easily

felt on the lateral and medial sides of the wrist, respectively. The styloid process of radius is located about 1.25
cm more distally.
4. Dorsal tubercle of the radius (Listers tubercle) can be
palpated on the posterior aspect of the distal end of the
radius in line with the cleft between index and middle
fingers.
FASCIAL COMPARTMENTS OF THE FOREARM

The forearm is enclosed in sheath of deep fascia of the forearm
(antebrachial fascia). It is attached to the posterior
subcutaneous border of the ulna. From the deep surface fascia,
septa pass between the muscles and some of these septa reach
the bone.
This deep fascia, together with interosseous membrane
and fibrous intermuscular septa divide the forearm into
several compartments, each having its own muscles, nerves,
and blood supply. Classically, the forearm is divided into
the two compartments: (a) anterior compartment and
(b) posterior compartment (Fig. 9.1).
The anterior compartment contains the structures on the
front of the forearm and the posterior compartment contains
the structure on the back of the forearm.
Near the wrist, the deep fascia presents two localized
thickenings, the flexor and the extensor retinacula, which
retain the digital tendons in position during hand movements.
B. On the Back of Forearm

1. Olecranon process of the ulna is the most prominent
bony elevation on the back of the elbow in the midline.
In an extended elbow, the tip of olecranon process lies in
a horizontal line with two epicondyles of the humerus
and in flexed elbow the three points when joined, form
an equilateral triangle.
2. Posterior border of the ulna is subcutaneous throughout
its length. It can be felt in the longitudinal furrow on the
back of forearm with elbow flexed. It separates the flexor
and extensor muscles of the forearm.
Flexor Retinaculum (Fig. 9.2)

The flexor retinaculum is a strong fibrous band formed by
the thickening of deep fascia in front of the carpus
(anatomical wrist). It is rectangular in shape and has roughly
the size and shape of a postage stamp. Like a postage stamp,
it presents two surfaces and four borders. Medially it is
attached to the pisiform and the hook of the hamate whereas
laterally it is attached to the tubercle of scaphoid and crest of
the trapezium. With carpus, it forms an osseofibrous tunnel
called carpal tunnel for the passage of flexor tendons of the
106
Flexor carpi radialis

Palmaris longus
Median nerve
Pronator teres
Flexor digitorum
superficialis
Brachioradialis
Ulnar nerve
Extensor carpi
radialis brevis
Flexor carpi ulnaris

Flexor digitorum
profundus
Extensor carpi
radialis longus
Ulna
Radius
Interosseous
membrane
Extensor digitorum
Extensor carpi
ulnaris
Extensor digiti minimi

Posterior
interosseous
nerve
Supinator
Fig. 9.1 Fascial compartments of the forearm. Cross section through the upper third of the forearm.
Radius
Ulna
Tubercle of
scaphoid
Pisiform bone
Crest of
trapezium
Hook of hamate
Flexor retinaculum
Fig. 9.2 Flexor retinaculum. (Source: Fig. 4.1, Page 33,

Selective Anatomy Prep Manual for Undergraduates, Vol. I,
Vishram Singh. Copyright Elsevier 2015, All rights reserved.)
digits. The flexor retinaculum is described in detail in

Chapter 11, page 139.
FRONT OF THE FOREARM

The following muscles, vessels, and nerves are to be studied
on the front of the forearm:
1. Muscles: Eight muscles, arranged in two groups.
2. Arteries: Two arteries, radial and ulnar.
3. Nerves: Three nerves, median, ulnar, and radial.
MUSCLES OF THE FRONT OF THE FOREARM

The muscles of the forearm are generally divided into two
groups: superficial and deep.
Superficial Muscles of Front of Forearm (Fig. 9.3)

This group comprises five muscles. From lateral to medial
side, these are:
1. Pronator teres.
2. Flexor carpi radialis.
3. Palmaris longus.
4. Flexor digitorum superficialis.
5. Flexor carpi ulnaris.
All these muscles are flexor of the forearm and have a
common originfrom the front of the medial epicondyle of
the humerus called common flexor origin.
Pronator Teres (Fig. 9.4)
Pronator teres is smallest and most lateral of the superficial
flexors of the forearm. It forms the medial boundary of the
cubital fossa.
Origin
It arises by two heads (a) superficial (humeral) head from the
medial epicondyle of the humerus, and (b) deep (ulnar)
head from the medial margin of the coronoid process of the
ulna.
Insertion
Into the rough impression on the middle one-third of the
lateral surface (most convex part) of the radius.
Nerve supply
By the median nerve.
Forearm
Common flexor origin
Origin
1. Superficial (humeral) head from
medial epicondyle of humerus
1. Pronator teres
2. Deep (ulnar) head from

medial margin of
coronoid process of ulna
2. Flexor carpi radialis

PRONATOR TERES
3. Palmaris longus
Insertion
Middle 1/3rd of
lateral surface of radius
4. Flexor digitorum
superficialis
5. Flexor carpi ulnaris
Pisiform bone
Flexor retinaculum
Fig. 9.4 Origin and insertion of the pronator teres.
Palmar aponeurosis
Ulnar artery passes deep to the deep head of pronator

teres, thus ulnar artery is separated from the median
nerve by the deep head of pronator teres in the region of
cubital fossa.
Fig. 9.3 Superficial muscles of the front of the forearm.
Actions
It is the main pronator of the forearm. It also helps in the
flexion of elbow.
Clinical testing
The pronator teres is tested by asking the patient to pronate
the forearm from supine position against resistance with
elbow flexed.
N.B.
Median nerve passes between the two heads of pronator
teres.
Flexor Carpi Radialis (Fig. 9.5)

Origin
From the medial epicondyle of humerus by a common flexor
origin.
Insertion
On to the anterior aspects of the bases of second and third
metacarpals.
Nerve supply
Actions
1. Acting with flexor carpi ulnaris, it flexes the wrist.
2. Acting with brachioradialis, it abducts the wrist.
107
108
Origin
Medial epicondyle of humerus
by a common flexor origin
N.B.
Morphologically, palmaris longus is a degenerating
muscle with small short belly and a long tendon. The
palmar aponeurosis represents the distal part of the tendon
of palmaris longus. The palmaris longus corresponds to
the plantaris muscle on the back of the leg.
It is absent on one or both sides (usually on the left) in
approximately 10% of people, but its actions are not
missed. Hence, its tendon is often used by the surgeons
for tendon grafting.
FLEXOR CARPI RADIALIS
Flexor Carpi Ulnaris (Fig. 9.6)

The flexor carpi ulnaris (FCU) is most medial of the
superficial flexors of the forearm.
Origin
Humeral head from:
Ulnar head from:
1. Medial margin of olecranon
process
2. Upper 2/3rd of posterior
border of ulna by
an aponeurosis
Insertion
Bases of 2nd and 3rd
metacarpals
FLEXOR CARPI ULNARIS
Fig. 9.5 Origin and insertion of the flexor carpi radialis.

N.B. The tendon of flexor carpi radialis (FCR) is a good guide
to the radial artery, which lies just lateral to it at the wrist.
Palmaris Longus
Origin
From the medial epicondyle of humerus by a common flexor
origin.
Insertion
Its long cord-like tendon crosses superficial to the flexor
retinaculum and attaches to its distal part and joins the apex
of palmar aponeurosis.
Insertion
Pisiform bone
Pisohamate ligament
Pisometacarpal ligament
Nerve supply
Actions
It flexes the wrist and makes the palmar aponeuroses tense.
Fig. 9.6 Origin and insertion of the flexor carpi ulnaris.
Forearm
Origin
It arises by two heads: a small humeral head and a large ulnar
head.
(a) humeral head from the medial epicondyle of the
humerus by a common flexor origin, and
(b) ulnar head from the medial margin of the olecranon
process and by an aponeurosis from the upper two-third
of the posterior border of the ulna.
Insertion
Into (a) pisiform bone and (b) hook of hamate and the base
of fifth metacarpal bone (through pisohamate and
pisometacarpal ligaments, respectively). The latter is the true
insertion because a sesamoid bone (pisiform) develops in its
tendon.
Nerve supply
By the ulnar nerve.
Actions
1. Acting with the extensor carpi ulnaris, it adducts the
wrist joint.
2. Acting with the flexor carpi radialis, it flexes the wrist
joint.
Origin
Humero-ulnar head
1. Medial epicondyle of
humerus
Median nerve
2. Medial collateral
ligament
Ulnar artery
Tendinous arch
joining two heads
3. Medial margin of
coronoid process
Origin
Radial head
Anterior oblique line of

radius
FLEXOR DIGITORUM
SUPERFICIALIS
N.B.
The ulnar nerve enters the forearm by passing between
the two heads of flexor carpi ulnaris, which are connected
to each other by a tendinous arch.
The tendon of flexor carpi ulnaris is a good guide to ulnar
nerve and ulnar artery, which lie on its lateral side at the
wrist.
Flexor Digitorum Superficialis (sublimis; Fig. 9.7)

The flexor digitorum superficialis (FDS) is the largest muscle
of the superficial group of muscles on the front of the
forearm. Actually speaking, it forms the intermediate muscle
layer between the superficial and deep groups of the forearm
muscles.
Origin
It arises by two heads:
(a) humero-ulnar head, from the medial epicondyle of
humerus, sublime tubercle on the medial margin of the
coronoid process of ulna and medial (ulnar) collateral
ligament of the elbow joint,
(b) radial head, from the anterior oblique line of the radius,
extending from the radial tuberosity to the insertion of
pronator teres (upper half of the anterior border of
radius).
Insertion
Middle phalanges of medial four fingers. The mode of
insertion is as follows. The muscles splits into two layers:
superficial and deep. The superficial layer forms two
Insertion
Middle phalanges of
fingers
Fig. 9.7 Origin and insertion of the flexor digitorum

superficialis.
tendons, which are inserted into middle phalanges of

middle and ring fingers. The deep layer also forms two
tendons, which are inserted into middle phalanges index
and little fingers. Before insertion each of the four tendons
splits, opposite the proximal phalanx, into medial and
109
110
lateral slips, which are inserted into the corresponding

sides of the middle phalanx.
2. Lateral half by the anterior interosseous nerve a branch

of the median nerve.
Nerve supply
Actions
FDP flexes the distal interphalangeal (DIP) joints of medial
four digits. It also helps to flex the wrist joint.
Actions
Flexor digitorum superficialis flexes the proximal
interphalangeal (PIP) joints of the medial four digits. Acting
more strongly, it also helps in flexion of the proximal
phalanges and wrist joint.
N.B.
The median nerve and ulnar artery pass downwards deep
to the fibrous arch/tendinous arch connecting the
humero-ulnar and radial heads of FDS.
The four tendons of FDS pass deep to flexor retinaculum
enclosed within a common synovial sheath, the ulnar
bursa.
Deep Muscles of the Front of the Forearm

There are three deep muscles of the front of the forearm, viz.
1. Flexor pollicis longus (placed laterally).
2. Flexor digitorum profundus (placed medially).
3. Pronator quadratus (placed distally).
Flexor Digitorum Profundus (Fig. 9.8)
The flexor digitorum profundus (FDP) is the most bulky and
powerful muscle on the front of forearm and provides main
gripping power to the hand.
Origin
1. From upper three-fourth of the anterior and medial
surfaces of the shaft of ulna and adjacent medial half of
the interosseous membrane.
2. By an aponeurosis from upper three-fourth of the
posterior border of ulna along with flexor and extensor
carpi ulnaris muscles.
3. From the medial side of olecranon and coronoid process
of ulna.
Insertion
On to the palmar aspect of the bases of distal phalanges of
medial four digits. The actual mode of insertion is as follows:
the muscle forms four tendons, which enter the palm by
passing deep to the flexor retinaculum. Opposite the proximal
phalanx of corresponding digit, the tendon perforates the
tendon of flexor digitorum superficialis and passes forward to
be inserted in palmar surface of the distal phalanx.
Nerve supply
1. Medial half by the ulnar nerve.
N.B.
Flexor digitorum profundus
(a) is most powerful and bulky muscle of the forearm,
(b) has dual innervation by median and ulnar nerves,
(c) provides most of the gripping power to hand,
(d) forms four tendons which enter the hand by passing
deep to flexor retinaculum, posterior to the tendons of
FDS in a common synovial sheathulnar bursa,
(e) forms most of the surface elevation medial to the
palpable posterior border of the ulna, and
(f) provides origin to the lumbrical muscles in the palm.
Clinical testing
The flexor digitorum profundus is tested by asking the
patient to flex the DIP joint, while holding the PIP joint in
extension.
The integrity of the median nerve in forearm is tested in
this way by using index finger and that of ulnar nerve by
using little finger.
Flexor Pollicis Longus (Fig. 9.8)
The flexor pollicis longus lies lateral to the FDP and clothes
the anterior aspect of the radius distal to the attachment of
supinator muscle.
Origin
From upper two-third of the anterior surface of the radius
below the anterior oblique line and adjoining part of the
interosseous membrane.
Insertion
Into the anterior surface of the base of distal phalanx of the
thumb.
Actions
It primarily flexes the distal phalanx of the thumb but
secondarily it also flexes proximal phalanx and first
metacarpal at the metacarpophalangeal (MP) and
carpometacarpal (CM) joints respectively.
N.B.
The anterior interosseous nerve and vessels descend on
interosseous membrane between flexor pollicis longus
and flexor digitorum profundus.
The flexor pollicis longus is the only muscle, which flexes
the interphalangeal joints of the thumb.
Forearm
Origin
1. Medial side of the olecranon and
coronoid processes of ulna
2. Upper 3/4th of anterior and medial

surfaces of shaft of ulna and adjoining
part of interosseous membrane
Origin
Upper 2/3rd of anterior surface of
radius below the oblique line and
adjoining part of interosseous membrane
3. Upper 3/4th of the

posterior border of ulna
FLEXOR DIGITORUM PROFUNDUS
FLEXOR POLLICIS LONGUS
Insertion
Base of distal
phalanx of thumb
Insertion
Bases of distal
phalanges of fingers
Fig. 9.8 Origin and insertion of the flexor digitorum profundus and flexor pollicis longus.
Clinical testing
The flexor pollicis longus is tested by asking the patient to
flex the interphalangeal joint of the thumb, while proximal
phalanx of the thumb is held in extension.
Pronator Quadratus (Fig. 9.9)

It is a flat quadrilateral muscle, which extends across the
front of the distal parts of the radius and ulna.
111
112
PRONATOR
QUADRATUS
Ulnar nerve
Brachial artery
Insertion
Lower 1/4th of
anterior surface
of radius
Origin
Oblique ridge on
lower 1/4th of
anterior surface of ulna
Deep branch of
radial nerve
Radial artery
Medial epicondyle
of humerus
Median nerve
Ulnar nerve
Ulnar artery
Superficial
radial nerve
Fig. 9.9 Origin and insertion of the pronator quadratus.
Origin
From an oblique ridge on the lower one-fourth of the anterior
surface of the shaft of ulna and medial part of this surface.
Insertion
1. The superficial fibres into the distal one-fourth of the
anterior border and anterior surface of the shaft of radius.
2. The deeper fibres into the triangular area above the
ulnar notch of the radius.
Deep palmar arch

(continuation of
radial artery)
Superficial
palmar arch
(continuation
of ulnar artery)
Nerve supply
By anterior interosseous nerve.
Actions
Pronator quadratus is the chief pronator of the forearm and
is assisted by pronator teres only in rapid and forceful
pronation.
ARTERIES OF THE FRONT OF THE FOREARM

(Fig. 9.10)
The arteries of the front of the forearm are ulnar and radial
arteries. They mainly supply blood to the hand through
superficial and deep palmar arterial arches.
The blood supply to the forearm is mainly derived from
the anterior and posterior interosseous arteries, the terminal
branches of the common interosseous artery, a branch of the
ulnar artery.
Ulnar Artery
Course
The ulnar artery is the larger terminal branch of the brachial
artery. It begins in the cubital fossa at the level of the neck of
the radius (or 1 cm distal to the flexion crease of the elbow).
It runs downwards and reaches the medial side of the forearm
Fig. 9.10 Arteries of the front of the forearm.
midway between the elbow and wrist. In the upper one-third

of forearm, the course is oblique (i.e., downwards and
medially) but in lower two-third it is vertical.
The median nerve lies medial to the artery 2.5 cm distal to
the elbow and then crosses the artery.
The ulnar nerve lies medial to the distal two-third of the
artery.
It enters the palm by passing in front of flexor
retinaculum lateral to the ulnar nerve and the pisiform
bone. It terminates in the hand by dividing into large
superficial and small deep branches. The superficial
branchthe continuation of the artery superficial palmar
arch, which anastomosis with superficial palmar branch of
the radial artery.
Relations
In the upper part of its course, it lies deep to superficial
flexor muscles. In the lower part of its course, it becomes
superficial and lies between the tendons of flexor carpi
Forearm
ulnaris and flexor digitorum superficialis. The details are

as under:
Anterior: The upper part of the ulnar artery is covered by
five superficial muscles of the forearm, viz.
(a) Pronator teres.
(b) Flexor carpi radialis.
(c) Palmaris longus.
(d) Flexor digitorum superficialis.
(e) Flexor carpi ulnaris.
The lower part of the ulnar artery is covered only
by the skin and superficial and deep fasciae.
Posterior: Only the origin of ulnar artery lies on brachialis,
while in the remaining whole part of its course it
lies on flexor digitorum profundus.
Medial:
(a) Ulnar nerve.
(b) Flexor carpi ulnaris.
Lateral: Flexor digitorum superficialis.
Branches
1. Muscular branches to neighboring muscles.
2. Anterior and posterior ulnar collateral (recurrent)
arteries, which take part in the arterial anastomosis
around the elbow joint.
3. Common interosseous artery, which arises from the
upper part of the ulnar artery and after a very short
course at the upper border of interosseous membrane, it
divides into anterior and posterior interosseous arteries.
4. Anterior and posterior ulnar carpal branches, which
take part in the formation of anterior and posterior
carpal arches.
5. Terminal branches are two, the larger superficial branch
continues as the superficial palmar arch, while the
smaller deep branch joins the deep palmar arch.
Aberrant ulnar artery: In about 3% of individuals, the ulnar
artery may arise high in the arm and passes superficial to
the flexor muscles of the forearm and is termed superficial
ulnar artery. This variation should always be kept in mind
while withdrawing blood samples or giving intravenous
injections, because if superficial ulnar artery is mistaken for
a vein it may be damaged and produce bleeding. Further, if
an irritating drug is injected into the aberrant artery, the
result could be fatal.
The anterior interosseous artery descends on the front of

interosseous membrane in company with the anterior
interosseous nerve (a branch of the median nerve). It pierces
the membrane at the upper border of pronator quadratus to
enter the posterior compartment of the forearm (cf. peroneal
artery of the leg), where it anastomoses with the posterior
interosseous artery and travels underneath the extensor
retinaculum to reach the dorsal aspect of the wrist to join the
dorsal carpal arch. The posterior interosseous artery is usually
smaller than the anterior. It passes posteriorly between the
oblique cord and proximal border of the interosseous
membrane. It accompanies the posterior interosseous nerve
(deep branch of the radial nerve). It gives rise to the
interosseous recurrent artery, which takes part in the arterial
anastomosis around the elbow joint.
Radial Artery
Origin and Course
The radial artery is the smaller terminal branch of the
brachial artery. It begins in cubital fossa at the level of the
neck of radius. It passes downwards to the wrist with lateral
convexity. In the upper part, it lies beneath the brachioradialis
on the deep muscles of the forearm. In the distal part of the
forearm, it lies on the anterior surface of the radius and is
covered only by the skin and fascia. The superficial radial
nerve lies lateral to the middle one-third of the radial artery.
The radial artery leaves the forearm by winding around the
lateral aspect of the wrist to reach the anatomical snuff-box
on the posterior surface of the hand. Its further course is
described in the hand.
Relations
Anterior: The upper part of the radial artery is overlapped
by brachioradialis, while its lower part is covered
only by the skin, and superficial and deep fasciae.
Posterior: The radial artery from above to downward lies
on the following structures:
(a) Biceps tendon.
(b) Supinator.
(c) Pronator teres.
(d) Flexor digitorum superficialis.
These structures together form the bed of the
radial artery.
N.B. The radial artery is quite superficial throughout its
whole course as compared to the ulnar artery.
Branches in the Forearm
Anterior Interosseous Artery (Fig. 9.21)

It along with the posterior interosseous artery is the main
source of blood supply to the forearm. It is also the deepest
artery on the front of the forearm.
1. Muscular branches to the lateral muscles of the forearm.

2. Radial recurrent artery arises in the cubital fossa and
takes part in the formation of arterial anastomose
around the elbow joint.
113
114
3. Palmar carpal branch, arises near the wrist and anastomosis with the palmar carpal branch of the ulnar artery.
4. Superficial palmar branch arises just above the wrist
and enters the palm of the hand by passing in front of
the flexor retinaculum. It joins the terminal part of the
ulnar artery to complete the superficial palmar arch.
Radial nerve
Ulnar nerve
Median nerve
Brachial artery
Examination of radial pulse: It is felt on the radial side of
the front of wrist where the radial artery lies on the anterior surface of the distal end of radius, and covered only
by the skin and fascia. At this site, the radial artery lies
between the tendon of flexor carpi radialis medially and
tendon of brachioradialis laterally. While examining the
radial pulse, thumb should not be used because it has its
own pulse, which may be mistaken for patients pulse. The
radial pulse is commonly used for examining the pulse
rate.
Volkmanns ischemic contracture (ischemic compartment syndrome): The sudden complete occlusion (e.g.,
due to tight plaster cast) or laceration (due to supracondylar fracture of the humerus) of the brachial artery can
cause paralysis of flexor muscles of the forearm due to
ischemia within a few hours. The muscles can tolerate
ischemia up to 6 hours only. Thereafter they undergo
necrosis and fibrous tissue replaces the necrotic tissue.
As a result, muscles shorten permanently producing a
flexor deformity characterized by flexion of the wrist,
extension of the MP joints, and flexion of the IP joints,
which leads to loss of hand power.
NERVES OF THE FRONT OF THE FOREARM (Fig. 9.11)

The nerves of the front of the forearm are median, radial,
and ulnar.
The radial and ulnar nerves as their name indicates run
along the radial and ulnar margins of the forearm inside the
radial and ulnar nerves. The median nerve, according its
name, runs in median region of the forearm.
Median Nerve
The median nerve is the principal nerve of the front of the
forearm and supplies all the muscles of the front of the
forearm except medial half of the flexor digitorum profundus
and flexor carpi ulnaris, which are supplied by the ulnar nerve.
The median nerve leaves the cubital fossa by passing
between the two heads of pronator teres. Here it crosses the
ulnar artery (from medial to lateral side) from which it is
separated by the deep head of pronator teres. Then along
with ulnar artery, it passes beneath fibrous arch joining two
Deep terminal
branch of radial
nerve (posterior
interosseous nerve)
Superficial terminal
branch of radial
nerve (superficial
radial nerve)
Ulnar artery
Radial artery
Fig. 9.11 Nerves on the front of the forearm.
heads of flexor digitorum superficialis and run deep to this

muscle on the surface of flexor digitorum profundus.
At the wrist, about 5 cm proximal to flexor retinaculum,
the median nerve emerges from behind the lateral border of
the flexor digitorum superficialis and lies behind the tendon
of palmaris longus. Note that in front of the wrist the median
nerve becomes superficial lying between the tendons of FDS
medially and FCR laterally and covered only partly by the
tendon of palmaris longus.
The median nerve enters the palm of the hand by passing
deep to the flexor reticulum through carpal tunnel.
1. Muscular branches in the cubital fossa to pronator teres,
flexor carpi radialis (FCR), palmaris longus, and flexor
digitorum superficialis (FDS).
2. Articular branches to the elbow and proximal radioulnar joint.
3. Anterior interosseous nerve arises in the upper part of
the forearm and passes downwards on the anterior
surface of the interosseous membrane between the
Forearm
Pronator teres
Anterior interosseous nerve
FCR
For details see Chapter 13.
Palmaris longus
FDS
4. Dorsal cutaneous branch arises in distal third of the

forearm. It passes medially between the tendon of flexor
carpi ulnaris and ulna to reach the dorsum of the hand.
FDP
FPL
Palmar cutaneous
branch
Pronator quadratus
Flexor retinaculum
Fig. 9.12 Branches of the median nerve in the forearm.
flexor pollicis longus (FPL) and flexor digitorum

profundus (FDP). It passes deep to pronator quadratus
and ends on the anterior surface of the carpus. It supplies
flexor pollicis longus, lateral half of the flexor digitorum
profundus, and pronator quadratus. It also provides
articular twigs to distal radio-ulnar and wrist joints.
4. Palmar cutaneous branch arises about 5 cm above the
wrist and passes forward in front of flexor retinaculum
to supply the skin over thenar eminence and central part
of the palm.
Radial Nerve
The radial nerve enters the cubital fossa from behind the
arm by descending between the brachioradialis and brachialis
muscles. In front of lateral epicondyle, it divides into two
terminal branchesdeep and superficial.
The deep branch of radial nerve winds around the neck of
radius between the two heads of supinator and enters the
posterior compartment of the forearm as posterior interosseous
nerve.
The superficial branch of the radial nerve (superficial
radial nerve) is the main continuation of the radial nerve. It
runs downwards under the cover of brachioradialis on the
lateral side of the radial artery. About 7.5 cm above the wrist,
the nerve leaves the artery, passes underneath the tendon of
brachioradialis to reach the posterior aspect of the wrist and
divides into terminal branches (four or five nerves), which
supply the skin of lateral two-third of the posterior aspect of
the hand and posterior surface of the proximal phalanges of
lateral 3 digits. The area of skin supplied by the radial nerve
on the dorsum of hand is variable.
For details see Chapter 13, page 174.
Surgical safe-side of forearm: Lateral side of the anterior
aspect of the forearm is considered to be the safe-side by
the surgeons because the branches of the median nerve,
the main nerve of the front of the forearm are mostly directed
medially to supply the muscles of the front of forearm. The
major nerve on the lateral side is the superficial radial nerve.
It is only a sensory branch of the radial nerve and runs deep
to the brachioradialis muscle in the proximal forearm.
Ulnar Nerve
The ulnar enters the front of the forearm by passing through
the gap between the two heads of flexor carpi ulnaris (cubital
tunnel). It then runs downward on the medial side of the
forearm between the FCU and FDP. It enters the palm of the
hand by passing in front of the flexor retinaculum lateral to
the pisiform bone.
In the distal two-third of the forearm, the ulnar artery is
lateral to the ulnar nerve.
Branches
1. Muscular branches to the flexor carpi ulnaris and medial
half of the FDP.
2. Articular branch to the elbow joint.
3. Palmar cutaneous branch arises in the middle of the
forearm and supplies the skin over the hypothenar
eminence. It sometimes supplies palmaris brevis.
RELATIONSHIP OF STRUCTURES ON THE FRONT OF

THE WRIST (Fig. 9.13)
The structures lying in front of the conventional wrist from
lateral to medial side are:
1.
2.
3.
4.
5.
6.
7.
Radial artery.
Tendon of flexor carpi radialis (FCR).
Tendon of palmaris longus.
Flexor digitorum superficialis.
Ulnar artery.
Ulnar nerve.
Tendon of flexor carpi ulnaris.
115
Forearm
Common extensor
origin
Brachioradialis
Extensor carpi
radialis longus
Lateral group of
superficial extensors
Extensor carpi
radialis brevis
Anconeus
Extensor carpi
ulnaris
Posterior group of
superficial extensors
Extensor digiti
minimi
Extensor digitorum
Listers tubercle
Abductor pollicis
longus
Extensor pollicis
brevis
Outcropping
muscles
Extensor pollicis
longus
Fig. 9.14 Arrangement of the superficial muscles on the back of the forearm.
2.
3.
4.
5.
Abductor pollicis longus (APL).

Extensor pollicis brevis (EPB).
Extensor pollicis longus (EPL).
Extensor indicis.
The three deep extensors of the forearm, which act on

thumb (abductor pollicis longus, extensor pollicis brevis, and
extensor pollicis longus) lie deep to the superficial extensors
and in order to gain insertion on the three short long bones
of thumb crop out (emerge) from the furrow in the lateral
part of the forearm between lateral and posterior groups of
superficial extensor. These three muscles are therefore
termed outcropping muscles.
The origin, insertion, nerve supply, and actions of

deep muscles of the back of forearm are presented in
Table 9.2.
N.B.
None of the deep muscles of the back of forearm cross
the elbow joint.
All of them arise from the radius, ulna, and interosseous
membrane.
All of them are supplied by the posterior interosseous
nerve (deep branch of the radial nerve).
117
118
Table 9.1 Origin, insertion, nerve supply, and actions of the superficial muscles of the back of the forearm (superficial
extensors)
Muscle
Origin
Insertion
Nerve supply
Actions
Lateral surface of the distal

end of radius just above the
styloid process
Radial nerve
Flexes the elbow joint.

Pronates the supinated
forearm to midprone
position
Supinates the pronated
forearm to midprone
position
Lateral side of the dorsal

surface of the base of
second metacarpal bone
Radial nerve
Acting with extensor

carpi ulnaris extends
the wrist
Acting with flexor
carpi radialis abducts
the wrist
Posterior interosseous
nerve before piercing
the supinator
-do-
Lateral group
Brachioradialis
(Fig. 9.15)
Upper two-third of the

lateral supracondylar ridge
of the humerus
Extensor carpi radialis Lower one-third of the

longus (ECRL)
lateral supracondylar ridge
of the humerus
Extensor carpi radialis By a common tendon from Lateral side of the dorsal
brevis (ECRB)
the lateral epicondyle of the surface of the base of third
humerus and lateral
metacarpal bone
ligament of the elbow joint
Posterior group
Gives rise to four tendons Posterior interosseous

for medial four digits.
nerve
By the extensor expansion
it is inserted into the
dorsum of middle and
terminal phalanges
Extends the medial four

digits. Can also extend
the wrist
Extensor digiti minimi By the common tendon

from the lateral epicondyle
Lies medial to the

extensor digitorum
tendon for the little
finger.
Through the extensor
expansion, it is inserted
into the dorsum of
middle and terminal
phalanges of little finger
nerve
Extends the little

finger
Helps in the extension
of the wrist
Extensor carpi ulnaris

(ECU)
By the common tendon

from the lateral epicondyle
and by an aponeurosis
from the upper two-third
of the posterior border of
ulna along with flexor carpi
ulnaris and flexor
digitorum profundus
Into a tubercle on the

medial side of the dorsal
surface of the base of the
fifth metacarpal
nerve
Acting with extensor

carpi radialis it
extends the wrist
Acting with flexor
carpi ulnaris it adducts
the wrist
Anconeus
From the back of the lateral Lateral side of the olecranon

epicondyle
process and upper onefourth of the posterior
surface of the ulna
Nerve to anconeus,
which arises from
radial nerve in spiral
groove and descends
through medial head
of the triceps brachii
Weak extensor of the

elbow joint
Extensor digitorum
By a common tendon from

the lateral epicondyle
Forearm
Origin
Upper 2/3rd of lateral
supracondylar ridge
BRACHIORADIALIS
Brachioradialis
Brachialis
Extensor carpi
radialis longus
Anconeus
Insertion
Lateral side of
distal end of radius
just above the
styloid process
Fig. 9.15 Origin and insertion of the brachioradialis.
Common extensor origin

(ECRB, ED, EDM, and ECU)
Fig. 9.16 Lateral aspect of the lower end of humerus

showing origin of seven superficial muscles of the back of
forearm (ECRB = extensor carpi radialis brevis, ED =
extensor digitorum, EDM = extensor digiti minimi, ECU =
extensor carpi ulnaris).
Extensor carpi radialis longus (ECRL) inserts on the

dorsal aspect of the base of 2nd metacarpal
Extensor carpi
ulnaris (ECU)
insets on the medial
side of the base of
5th metacarpal
Fifth metacarpal
Extensor carpi radialis

brevis (ECRB)
insets on the bases of
2nd and 3rd metacarpals
First metacarpal
Listers
tubercle
Tendon of
extensor
digitorum
Tendon of
extensor
carpi ulnaris
Tendon of
extensor indicis
Proximal
phalanx
Middle
phalanx
Distal
phalanx
Fig. 9.17 Insertion of the extensor carpi ulnaris, extensor

carpi radialis longus, and extensor carpi radialis brevis.
Fig. 9.18 Insertion of the extensor digitorum, extensor

carpi ulnaris, and extensor indicis.
119
120
Table 9.2 Origin, insertion, nerve supply, and actions of the deep muscles of the back of the forearm (deep extensors of
forearm)
Muscle
Origin
Supinator (Fig. 9.20)
Abductor pollicis
longus (APL)
Insertion
Nerve supply
Action
Lateral epicondyle
Lateral ligament of the
elbow joint
Annular ligament
Supinator crest of ulna
and from the
triangular area in front
of it
Upper one-third of the

posterior, lateral, and
anterior surfaces of the
radius
nerve before piercing the
supinator
Supination of the
forearm
Lateral part of the

posterior surface of
ulna below the
anconeus
Middle one-third of
the posterior surface
of radius (below the
posterior oblique line)
and intervening
interosseous
membrane
Lateral side of the base

of first metacarpal
nerve
Abducts the thumb
Extensor pollicis
brevis (EPB)
From a small area on the

radius below the origin
of abductor pollicis
longus and from
adjoining interosseous
membrane
Dorsal surface of the

base of proximal phalanx nerve
of thumb
Extends the thumb at

metacarpophalangeal
joint and extends the
carpometacarpal joint
Extensor pollicis longus
From lateral part of

middle one-third of the
posterior surface of ulna
and adjoining
interosseous membrane
Dorsal surface of the

base of distal phalanx of
thumb
nerve
Extends the joints of

thumb
of the wrist
Extensor indicis
From the posterior

The tendon lies medial Posterior interosseous
surface of ulna below the
to the extensor
nerve
origin of extensor
digitorum tendon for
pollicis longus and also
the index finger
from the adjoining
Through the extensor
expansion, it is
inserted into the
dorsum of middle and
distal phalanges of the
index finger
Extends the index

finger
of the wrist
Forearm
Origin
Supinator
Supinator crest of ulna
Origins
Abductor pollicis longus
1. Post surface of ulna

2. Interosseous membrane
3. Posterior surface of radius
Insertion
Supinator
Upper 1/3rd of the lateral
surface of radius
1. Posterior surface of ulna

Extensor pollicis brevis
1. Posterior surface of radius

Extensor indicis
1. Post surface of ulna

2. Adjoining part of interosseous
membrane
Extensor indicis
L
S
Ulna
Base of proximal phalanx of thumb
Radius
APL
Base of distal phalanx of thumb

Extensor indicis
Ulnar side of extensor digitorum

tendon for index finger
EPL
EPB
EI
Insertions
Radial side of base of 1st metacarpal
Fig. 9.19 A, Origin of five deep muscles of the back of forearm from the posterior aspects of radius and ulna
(S = supinator, APL = abductor pollicis longus, EPL = extensor pollicis longus, EPB = extensor pollicis brevis, EI = extensor
indicis); B, Origin and insertion of the deep muscles on the back of the forearm (L = Listers tubercle).
121
122
Anterior border of
radius
Origin
1. Lateral epicondyle of
humerus
2. Radial collateral
ligament
3. Annular ligament
Extensor
retinaculum
Styloid process of ulna

Triquetral
Pisiform
Origin (contd)
4. Supinator crest
5. Adjoining part of
triangular area
SUPINATOR
Insertion
Upper 1/3rd of lateral
surface of radius
Fig. 9.21 Extensor retinaculum.
Fig. 9.20 Origin and insertion of the supinator muscle.
EXTENSOR RETINACULUM
The deep fascia on the back of the wrist is thickened to form
an oblique fibrous band called extensor retinaculum
(Fig. 11.29). It is directed downwards and laterally, and about
2 cm broad vertically.
Attachments (Fig. 9.21)

The medial end of extensor retinaculum is attached to the
styloid process of ulna, triquetral, and pisiform bones.
Its lateral end is attached to the lower part of the anterior
border of the radius.
Compartments (Fig. 9.22)

The space deep to the extensor retinaculum is divided into
six compartments by five septa extending from retinaculum
to the dorsal aspects of the lower ends of radius and ulna.
The compartments are numbered I to VI from lateral to
medial side.
The structures passing through these compartments are
listed in Table 9.3.
N.B. As the tendons pass across the dorsum of wrist, they
are enclosed within synovial sheaths called synovial tendon
sheaths, which reduce the friction of extensor tendons as
they pass through the osseofibrous tunnelsthe
compartments under the extensor retinaculum.
Functions
It holds the extensor tendon in place on the back of wrist and
prevents their bowstrings when the hand is extended at the
wrist joint.
Posterior interosseous nerve
Extensor digitorum
Extensor indicis
Extensor carpi
radialis brevis
Anterior interosseous artery

Extensor carpi
radialis longus
Extensor
pollicis brevis
Abductor
pollicis longus
Radius
Ulna
Fig. 9.22 Transverse section of the forearm just above the wrist showing structures passing deep to the extensor retinaculum.
Forearm
Table 9.3 Structures passing through various compartments

beneath the extensor retinaculum of wrist
Compartment
I
II
III
IV
V
VI
Structure/structures, passing through

Abductor pollicis longus (APL)
Extensor pollicis brevis (APB)
Extensor carpi radialis longus (ECRL)
Extensor carpi radialis brevis (ECRB)
Extensor pollicis longus (EPL)
Extensor digitorum (ED)
Extensor indicis (EI)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (EUC)
POSTERIOR INTEROSSEOUS NERVE (Fig. 9.23)

Origin and Course
The posterior interosseous nerve is the deep terminal branch
of the radial nerve. It is motor and chief nerve of the back of
the forearm. It begins in the cubital fossa as one of the two
terminal branches of radial nerve at the level of lateral

epicondyle of humerus. It leaves the cubital fossa by winding
around the lateral side of the neck of radius in the substance
of supinator. After emerging from supinator, it runs in the
fascial plane between superficial and deep extensor muscles.
At the lower border of extensor pollicis brevis, it passes deep
to the extensor pollicis longus to lie on the posterior surface
of interosseous nerve, on which it runs downwards up to the
wrist where it ends into a pseudoganglion.

1. Muscular branches
(a) Before piercing supinator, it gives branches to the
extensor carpi radialis brevis and supinator.
(b) While passing through supinator, it gives another
branch to the supinator.
(c) After emerging from supinator, it gives branches to
three superficial extensors (extensor digitorum,
extensor digiti minimi, and extensor carpi ulnaris)
and all deep extensors.
Radial nerve
Brachioradialis
Radial nerve
Ext. carpi radialis longus
Posterior
interosseous nerve
(deep terminal branch of
radial nerve)
Superficial radial nerve

Supinator
ECRB
Superficial
extensors of
forearm
Ext. digitorum
Posterior
interosseous nerve
Ext. digiti minimi
Posterior
interosseous artery
Ext. carpi ulnaris

(superficial terminal
branch of radial nerve)
Supinator
Oblique cord
Common
interosseous
artery
Recurrent
interosseous artery
Interosseous membrane
Abductor
pollicis longus
Extensor
pollicis brevis
Anterior interosseous
artery
APL
EPL
Extensor
pollicis longus
EPB
Ext. indicis
Anterior
interosseous artery
Pseudoganglion
Fig. 9.23 Branches of the posterior interosseous nerve.
Pronator
quadratus
Pseudoganglion
Fig. 9.24 Course and relations of the posterior interosseous

artery.
123
124
2. Articular branches to the wrist joint, distal radio-ulnar

joint, and carpal joints.
N.B. All the muscles on the back of forearm are supplied by
the posterior interosseous nerve except brachioradialis,
extensor carpi radialis longus, and anconeus, which are
supplied by the radial nerve directly.
Lesion of posterior interosseous nerve: The posterior
interosseous nerve (i.e., deep terminal branch of the radial
nerve) may be damaged during surgical exposure of the
head of radius in fracture proximal end of radius. Since the
extensor carpi radialis longus is spared wrist drop does not
occur.
POSTERIOR INTEROSSEOUS ARTERY

The posterior interosseous artery (Fig. 9.24) is a smaller
terminal branch of the common interosseous artery from
ulnar artery. It begins in the cubital fossa, enters the back of
the forearm by passing through the gap between the oblique
cord and upper margin of the interosseous membrane. From
here, it passes between supinator and abductor pollicis
longus to accompany the posterior interosseous nerve. In the
lower part of the forearm, it becomes markedly reduced and
ends by anastomosing with the anterior interosseous artery.
In the lower part of forearm, the anterior interosseous artery
enters the back of the forearm by piercing interosseous
membrane just above the pronator quadratus and supplies
low one-fourth of the back of the forearm. The posterior
interosseous artery in the cubital fossa gives interosseous
recurrent artery, which takes part in the formation of
anastomosis around the elbow joint.
CHAPTER
10
Elbow and Radioulnar Joints
TYPE
ELBOW JOINT
The elbow joint is a joint between the lower end of the
humerus and upper ends of the radius and ulna. It actually
includes two articulations: (a) humero-ulnar articulation,
between the trochlea of the humerus and trochlear notch
of the ulna, and (b) humero-radial articulation, between
the capitulum of the humerus and the head of radius. On
the surface, the joint line of elbow is situated 2 cm below
the line joining the two epicondyles of humerus.
The complexity of elbow joint is further increased by
its continuity with superior radio-ulnar joint. Thus
there are three articulations in the elbow region, viz.
(a) humero-ulnar, (b) humero-radial, and (c) superior
(proximal) radio-ulnar. These are called cubital
articulations (Fig. 10.1).
Capitulum
It is a hinge type of synovial joint.
ARTICULAR SURFACES
The upper articular surface is formed by the capitulum and
the trochlea of the lower end of the humerus.
The lower articular surface is formed by the upper surface
of the head of the radius and trochlear notch of the ulna.
The capitulum is a rounded hemispherical eminence and
possesses smooth articular surface only on its anterior and
inferior aspects.
The trochlea is medial to capitulum and resembles a
pulley. The medial flange of trochlea projects to a lower level
than its lateral flange.
Humerus
Humerus
Trochlea
Humero-radial
articulation
Humero-ulnar
articulation
Olecranon
Radial collateral
ligament
Superior radioulnar articulation
Capitulum
Ulnar collateral
ligament
Trochlea
Head of
radius
Trochlear
notch of ulna
Head of radius
Radial notch of ulna
Quadrate ligament
Radius
A
Supinator fossa
Ulna
Radius
Ulna
Fig. 10.1 Components of the elbow joint: A, schematic diagram; B, radiograph of normal elbow joint (anteroposterior view).
(Source: Fig. 7.70D, Page 681, Grays Anatomy for Students, Richard L Drake, Wayne Vogl, Adam WM Mitchell. Copyright
Elsevier Inc. 2005, All rights reserved.)
The trochlear notch of ulna is formed by the upper

surface of the coronoid process and anterior surface of the
olecranon process.
The upper end of radius is circular in outline and slightly
depressed in the center.
Attachment
N.B. The distal end of humerus has three non-articular

fossae: (a) olecranon fossa, a deep hollow above the
posterior part of the trochlea. It lodges the tip of olecranon
process of ulna during extension of the elbow, (b) coronoid
fossa, a small hollow above the anterior surface of the
trochlea. It lodges the anterior margin of coronoid process
of ulna during flexion of the elbow, and (c) radial fossa,
another small hollow lateral to the coronoid fossa, just above
the capitulum. It lodges the anterior margin of the head of
radius during flexion of the elbow.
Below, it is attached to the anterior and medial margins

of the coronoid process of ulna, upper margin of the annular ligament, and upper and medial margins of the olecranon process. Note, it is not attached to the radius.
Above, it is attached to the medial epicondyle, upper

margins of radial, coronoid, and olecranon fossae, and
lateral epicondyle of the humerus, i.e., it encloses all the
non-articular fossae at the lower end of the humerus.
To facilitate the movements of flexion and extension,

the anterior and posterior aspects of the capsule are
thinner than the sides. The inner surface of the joint
capsule and non-articular bony parts inside the capsule
are lined by synovial membrane (Fig. 10.3). The synovial
membrane forms a crescentic fold between humero-radial
and humero-ulnar parts, which contains an extrasynovial
fat. Between the synovial membrane and joint capsule,
there are three other fat pads occupying olecranon,
coronoid, and radial fossae. The synovial membrane of
elbow joint is continuous inferiorly with the synovial
membrane of the superior radio-ulnar joint.
LIGAMENTS (Figs 10.2 and 10.3)

CAPSULAR LIGAMENT (JOINT CAPSULE)
It is a fibrous sac enclosing the joint cavity (Fig. 10.2). The
inner surface of the capsule is lined by the synovial membrane.
Capsular
ligament
Coronoid
fossa
Radial fossa
Medial
epicondyle
Capitulum
Capsular
ligament
Trochlea
Trochlea
A
Olecranon
fossa
Medial
epicondyle
Capitulum
Olecranon process
Capsular ligament
Trochlear notch
Head of
radius
Annular
ligament
Ulna
Radius
C
Fig. 10.2 Attachment of capsular ligament of elbow joint: A, anterior aspect; B, posterior aspect; C, anterosuperior
aspect.
127
2. Subcutaneous olecranon bursa, a large bursa between

skin and subcutaneous triangular area on the posterior
surface of the olecranon.
3. Bicipitoradial bursa, a small bursa separating biceps
tendon from smooth anterior part of the radial tuberosity.
4. A small bursa separating the biceps tendon from the
oblique cord.
Lateral epicondyle
of humerus
Radial collateral
ligament
Annular ligament
STABILITY OF THE ELBOW JOINT
Radius
In adults, the elbow joint is quite stable due to the following

two factors:
Fig. 10.5 Radial collateral ligament.
brachii. The last three structures are

separated from joint capsule by brachialis.
Posterior:
(a) Tendon of triceps (b) anconeus.
Medially:
(a) Flexor carpi ulnaris, (b) ulnar nerve
(posteromedially) (c) common flexor origin
of the muscles of forearm (anteromedially).
Laterally
(a) Spinator (b) common extensor origin of
(posterolateral): muscles of forearm muscles, (c) extensor carpi
radialis brevis.
1. Pulley-shaped trochlea of humerus fits properly into

jaw-like trochlear notch of ulna.
2. Strong ulnar and radial collateral ligaments.
BLOOD SUPPLY
The blood supply of elbow joints is by arterial anastomosis
around the elbow formed by the branches of brachial, radial,
and ulnar arteries.
NERVE SUPPLY
BURSAE RELATED TO THE ELBOW JOINT
Four important bursae are related to the elbow joints
(a) two in relation to the triceps insertion and (b) two in
relation to the biceps insertion:
1.
Subtendinous olecranon bursa, a small bursa between

triceps tendon and upper surface of the olecranon process.
Nerve supply of elbow joint is by articular branches from:

(a) radial nerve (through its branch to anconeus),
(b) musculocutaneous nerve (through its branch to
brachialis),
(c) ulnar nerve, and
(d) median nerve.
Brachialis muscle
Tendon of biceps
Anterior
relations
Brachial artery
Median nerve
Brachialis
Extensor carpi
radialis brevis
Flexor carpi
ulnaris
Lateral
relations
Common
flexor origin
Common
extensor origin
Ulnar nerve
Nerve to
anconeus
Anconeus
Posterior relations
Fig. 10.6 Relations of the elbow joint.
Tendon
of triceps
Cut edge of
joint capsule
Medial
relations
129
130
Table 10.1 Movements of the elbow joint

Movements
Muscles producing movements
Flexion
Extension
Brachialis
Biceps brachii
Brachioradialis*
Triceps
Anconeus
*The brachioradialis acts most effectively in midprone position as when

medical students walk by putting their aprons over their shoulders.
The carrying angle disappears during pronation and full

flexion of forearm.
The forearm comes into line with the arm in the midprone
positionthe position in which the hand is mostly used.
The carrying angle varies from 5 to 15 and is more
pronounced in females. The wider carrying angle in females
avoids rubbing of forearms with the wider female pelvis
while carrying loads, e.g., buckets filled with water from one
place to another.
MOVEMENTS
Being an uniaxial joint, the elbow joint allows only flexion
and extension. The range of flexion is about 140. These
movements and muscles producing them are presented in
Table 10.1.
CARRYING ANGLE (Fig. 10.7)

The transverse axis of elbow joint is not transverse but
oblique being directed downwards and medially. This is
because medial flange of trochlea lies about 6 mm below its
lateral flange. Consequently when the elbow is extended the
arm and forearm do not lie in straight line, rather forearm is
deviated slightly laterally. This angle of deviation of long axis
of forearm from long axis of arm is termed carrying angle.
Long axis of
arm
Long axis of
forerarm
Carrying
angle
10 to 15
Lateral (outward)
deviation of extended and
supinated forearm
Fig. 10.7 Carrying angle.
Elbow effusion: The distension of elbow joint due to

effusion within its cavity occurs posteriorly because
capsule of the joint is thin posteriorly and covering fascia
is also thin. The joint is aspirated by inserting a needle on
the posterolateral side, above the head of radius with
elbow at the right angle.
Dislocation of elbow: Posterior dislocations of elbow are
more common and are often associated with fracture of the
coronoid process. The dislocation invariably occurs by falling
on an outstretched hand. The triangular relationship
between the olecranon and the epicondyles of humerus is
lost. Note, in normal flexed elbow the tip of olecranon
process and two epicondyles of humerus form an equilateral
triangle (Fig. 10.8).
The reduction, if done early, is achieved fairly easily by
first giving traction to overcome spasm and then flexing
the forearm to lever joint back into the place.
Nursemaids elbow/pulled elbow (subluxation of head of
radius; Fig. 10.9) occurs in preschool children, 13 years old
when the forearm is suddenly pulled in pronation. The head
of radius comes out of annular ligament and the elbow is
kept slightly flexed and pronated. An attempt to supinate the
forearm causes severe pain.
The reduction is easily achieved by supinating and
extending the elbow and simultaneously applying direct
pressure posteriorly on the head of radius.
Tennis elbow (lateral epicondylitis; Fig 10.10): It is a
clinical condition characterized by pain and tenderness
over the lateral epicondyle of the humerus with pain during
abrupt pronation. It occurs due to:
(a) sprain of lateral collateral ligament of elbow joint, or (b) a
tear of the fibres of extensor carpi radialis brevis, or (c) an
inflammation of bursa underneath the extensor carpi radialis
brevis, or (d) strain or tear of common extensor origin.
Golfers elbow (medial epicondylitis; Fig 10.10): It is a
clinical condition characterized by pain and tenderness
over the medial epicondyle of the humerus. It occurs due
to strain or tear of common flexor origin with subsequent
inflammation of medial epicondyle, following repetitive use
of superficial flexors of forearm as during playing golf.
Students elbow (Miners elbow; Fig 10.11) is
characterized by a round fluctuating painful swelling over
the olecranon. It occurs due to inflammation of
subcutaneous olecranon bursa lying over subcutaneous
triangular area on the posterior aspect of the olecranon
process.
Lateral epicondyle
Medial
epicondyle
Olecranon process
A
Fig 10.8 A, Formation of equilateral triangle by three bony points behind flexed elbow; B, elbow joint with normal relationship
of three bony points of the elbow; C, posterior dislocation of the elbow joint causing disturbance in the relationship of three
bony points of the elbow due to backward and upward displacement of the olecranon process. (Source: Fig. 2.2(A): B; Fig.
2.2(B): A; and B, Page 52, Clinical and Surgical Anatomy, 2e, Vishram Singh. Copyright Elsevier 2007, All rights reserved.)
Radial
collateral
lig.
Annular lig.
Lateral epicondylitis
(Tennis elbow)
Radial
collateral
lig.
Medial
epicondylitis
(Golfers elbow)
Annular lig.
Fig. 10.9 Pulled elbow: A, head of radius within

cup-shaped annular ligament; B, head of radius displaced
down from the annular ligament.
Nerve entrapments (compressions) around elbow:

The nerve entrapments around elbow are common and
cause pain, muscle atrophy, and weakness in the area
supplied by the entrapped nerve. The examples are:
(a) Median nerve entrapment: The median nerve may be
compressed: (a) where it passes between the two
heads of pronator teres or (b) where it passes deep to
fibrous arch between humero-ulnar and radial heads
of flexor digitorum superficialis.
(b) Ulnar nerve entrapment: The ulnar nerve may be
compressed (a) where it passes posterior to the
medial epicondyle of the humerus (commonest site)
or (b) where it passes through cubital tunnel formed
by tendinous arch joining the humeral and ulnar
heads of flexor carpi ulnaris.
(c) Posterior interosseous nerve entrapment: The
posterior interosseous nerve may be compressed
(a) where it passes deep to the arcade of Frohse, a
musculoaponeurotic structure at the proximal edge of
supinator muscle or (b) where it passes through the
substance of supinator muscle.
Fig. 10.10 Lateral and medial epicondylitis.
Olecranon
process of ulna
Inflamed and enlarged
subcutaneous olecranon bursa
Students elbow
Fig. 10.11 Students (Miner's) elbow.
RADIO-ULNAR JOINTS
The radius and ulna form two joints between them; one at
their upper ends and one at their lower ends. They are called
superior and inferior radio-ulnar joints (Fig. 10.12). Both
these joints are synovial joints of pivot variety. They are
131
132
Capitulum
Radial collateral
ligament of elbow joint
Annular ligament
Head of radius
Trochlear notch
Radial notch of
ulna
Superior radio-ulnar
joint
Oblique cord
Trochlear
notch
Ulna
Lateral collateral
ligament of elbow joint
Annular ligament
Coronoid process of ulna
Radius
Interosseous
membrane
Middle radio-ulnar
joint
Recessus
sacciformis
Inferior radio-ulnar
joint
Articular disc
Fig. 10.12 Radio-ulnar joints. Figure in the inset on the left shows socket for head of radius (formed by annular ligament).
uniaxial joints permitting only rotation. The shafts of radius

and ulna are also connected to each other by interosseous
membrane. This union between radius and ulna is sometimes
termed middle radio-ulnar joint.
SUPERIOR (PROXIMAL) RADIO-ULNAR JOINT

TYPE
It is a pivot type of synovial joint.
ARTICULAR SURFACES
The articulating surfaces are: (a) circumference of radial
head and (b) fibro-osseous ring made by radial notch of ulna
and annular ligament.
LIGAMENTS
1. Capsular ligament (joint capsule): The fibrous capsule
surrounds the joint. It is continuous with that of elbow
joint and is attached to the annular ligament.
2. Annular ligament: It is a strong fibrous band, which

encircles the head of radius and holds it against the
radial notch of ulna. It forms about four-fifth of the
fibro-osseous ring within which the head of radius
rotates. Medially the annular ligament is attached
to the margins of radial notch of ulna. The upper
margin of the ligament is continuous with the capsule
of the shoulder joint and its lower part becomes
narrow and embraces the neck of radius. The inner
surface of annular ligament is covered by a thin layer
of cartilage. Laterally, it blends with the radial
collateral ligament.
3. Quadrate ligament: It is thin, fibrous ligament, which
extends from neck of radius to the upper part of
supinator fossa of ulna just below the radial notch.
Synovial membrane: It lines the inner aspect of the joint
capsule and annular ligament of superior radio-ulnar
joint and is continuous with the synovial membrane of
the elbow joint. It is prevented from herniation by
quadrate ligament.
RELATIONS
Anteriorly and laterally: Supinator muscle.
Posteriorly: Anconeus muscle.
BLOOD SUPPLY
By articular branches derived from arterial anastomosis on
the lateral side of the elbow joint.
NERVE SUPPLY
By articular branches from musculocutaneous, median,
radial, and ulnar nerves.
MOVEMENTS
Supination and pronation.
process of ulna and its base to the lower margin of the

ulnar notch of radius. The articular disc separates the
inferior radio-ulnar joint from the wrist joint.
3. Stability of elbow joint: The main factors providing stability to elbow joint are:
(a) Wrench-shaped articular surface of the olecranon
process of ulna and pulley-shaped trochlea of
humerus.
(b) Strong medial and lateral collateral ligaments.
RELATIONS
Anteriorly: Flexor digitorum profundus.
Posteriorly: Extensor digiti minimi.
BLOOD SUPPLY
INFERIOR (DISTAL) RADIO-ULNAR JOINT
By anterior and posterior interosseous arteries.
TYPE
NERVE SUPPLY
Synovial joint of pivot variety.
ARTICULAR SURFACES
By anterior and posterior interosseous nerves.

A brief comparison of superior and inferior radio-ulnar
joints is presented in Table 10.2.
The articulating surfaces are (a) convex head of ulna, and

(b) concave ulnar notch of radius.
MOVEMENTS
Supination and pronation.
LIGAMENTS
1. Capsular ligament (joint capsule): It is a fibrous sac
which encloses the joint cavity and is attached to the
margins of articular surfaces. The inner surface of the
joint capsule is lined by synovial membrane. The synovial lining of the joint sends an upward prolongation in
front of the lower part of the interosseous membrane
called recessus sacciformis. The synovial cavity of joint
does not communicate with the synovial cavity of the
wrist joint.
2. Articular disc: It is a triangular fibrocartilaginous disc
and is sometimes referred to by clinicians as triangular
ligament. Its apex is attached to the base of the styloid
INTEROSSEOUS MEMBRANE OF
THE FOREARM (Fig. 10.8)
It is the fibrous sheet, which stretches between the
interosseous borders of the radius and ulna. It holds these
bones together and does not interfere with the movements,
which take place between them. The oblique cord of fibrous
tissue extending from lateral side of ulnar tuberosity to the
lower end of radial tuberosity also helps to hold the radius
and ulna together. This union between radius and ulna is
sometimes termed middle radio-ulnar joint. This is a
syndesmosis type of fibrous joint.
Table 10.2 Superior and inferior radio-ulnar joints

Features
Superior radio-ulnar joint
Inferior radio-ulnar joint
Type
Pivot type of synovial joint
Pivot type of synovial joint
Articular surfaces
Joint cavity
Circumference of head of radius

Fibro-osseous ring formed by annular
ligament and radial notch of ulna
Communicates with the cavity of elbow joint
Head of ulna
Ulnar notch of radius
Does not communicate with the cavity of wrist joint
Prime stabilizing factor
Annular ligament
Articular disc
Movements
Supination and pronation
Supination and pronation
133
Table 10.3 Movements of supination and pronation

Movements
Muscles producing movements
Supination
Pronation*
Supinator
Biceps brachii supinates the forearm while
the elbow is flexed
Brachioradialis supinates the pronated
forearm to midprone position
Pronator teres
Pronator quadratus
Brachioradialis, pronates the supinated
forearm to midprone position
*The flexor carpi radialis, palmaris longus and gravity also help in pronation.
Morphologically, movements of supination and pronation

are evolved for picking up the food and taking it to the
mouth. The food is picked up in pronation and put in mouth in
supination.
In supination, the radius and ulna lie parallel to each

other. In pronation, there is rotation of lower end of radius
along with articular disc on the head of ulna. As a result,
the lower end of radius crosses in front of the lower end of
ulna. Simultaneously the head of radius rotates within the
fibro-osseous ring formed by the annular ligament and the
radial notch of the ulna.
The movements of the supination and pronation, and
muscle producing them are given in Table 10.3.
N.B. The supination is more powerful than pronation because:
(a) it has antigravity movement, and (b) it is performed by
powerful muscles, viz. biceps brachii. The pronation is less
powerful than supination because it is performed by less
powerful muscles, viz. pronator quadratus and pronator teres.
Therefore, supination movements are used for tightening the
nuts and bolts, whereas pronation movements are used for
loosening/opening the nuts and bolts.
135
CHAPTER
11
Hand
The hand (L. Manus) is the distal part/segment of the upper

limb. It is a complex and highly evolved anatomic structure,
which provides primary touch input to the brain and enables
humans to perform complex fine motor tasks by way of its
free movements, power grip, precision grip, handling, and
pinching. The hand is mans great physical asset. It has enabled
him to use various tools that his brain has invented. Therefore,
good understanding of its structure and functions is essential.
Everything that the doctors do to the hand should be aimed at
restoring or maintaining its function. The movements of the
hand occur primarily at the wrist joint or radio-carpal joint
formed by the articulation of radius and first row of the carpal
bones (e.g., scaphoid, lunate, and triquetral).
The hand consists of four functional units, viz.
1.
2.
3.
4.
Carpus.
Thumb.
Index finger.
A unit comprising middle, ring, and little fingers.
The carpus (first unit) provides a stabilizing platform for

the three mobile units (2, 3, and 4).
The hand contains carpal bones, metacarpal bones, and
phalanges.
3. Pisiform bonecan be felt at the base of hypothenar

eminence medially. It lies deep to medial end of distal
transverse crease of the wrist.
4. Hook of hamatecan be felt one fingers breadth distal
to the pisiform bone.
SKIN OF THE PALM

The skin of the palm presents the following characteristic
features:
1. It is thick to withstand wear and tear during work.
2. It is richly supplied by the sweat glands but contains no
hair or sebaceous glands.
3. It is immobile as it is firmly attached to the underlying
palmar aponeurosis.
4. It presents several longitudinal and transverse creases
where the skin is firmly bound to the deep fascia.
N.B. To improve the grip the skin of the palm is ridged and
furrowed and devoid of greasy sebaceous glands.
N.B. Anatomically, the term wrist refers to carpus (carpal

region) consisting of eight carpal bones and lies between
forearm and hand but in general usage, wrist refers to distal
end of forearm just proximal to distal ends of radius and
ulna, around which the wrist watch is worn.
PALMAR ASPECT OF THE HAND

SURFACE LANDMARKS (Fig. 11.1)
1. Tubercle of scaphoidcan be felt at the base of thenar
eminence, just lateral to the tendon of flexor carpi
radialis. It is located deep to the lateral part of distal
transverse crease of the wrist.
2. Tubercle/crest of trapeziumcan be felt on deep
palpation, distolateral to the tubercle of scaphoid.
Hook of hamate
Crest of trapezium
Pisiform bone
Tubercle of scaphoid
Fig. 11.1 Surface landmarks.
138
Flexion Creases of the Wrist, Palm, and Fingers (Fig. 11.2)

1. Flexion creases of the wrist (wrist creases): The palmar
aspect of the wrist presents two transverse flexion
creases, viz.
(a) Proximal wrist crease.
(b) Distal wrist crease.
They are produced as a result of folding of the skin due to
repeated flexion of the wrist. The distal wrist crease
corresponds to the proximal border of the flexor retinaculum.
2. Palmar flexion creases: Usually there are four major
palmar creasestwo horizontal and two longitudinal
which together roughly form an M-shaped pattern:
(a) Longitudinal palmar creases:
(i) Radial longitudinal crease (lifeline of the
palmistry): It partly encircles the thenar
eminence (ball of the thumb) and is formed
due to action of short muscles of the thumb.
(ii) Midpalmar longitudinal crease (line of fate in
palmistry): It indicates the lateral limit of the
hypothenar eminence (ball of the little finger).
It is formed due to the action of short muscles
of the little finger.
(b) Transverse palmar creases:
(i) Distal transverse palmar crease: It begins at or
near the interdigital cleft between the index and
little fingers and crosses the palm (with slight
distal convexity) superficial to the shafts of the
third, fourth, and fifth metacarpals.
(ii) Proximal transverse palmar crease: It commences
at the lateral border of the palm in common with
Distal digital
flexion crease
Middle digital
flexion crease
the radial longitudinal crease, superficial to the

head of the second metacarpal. It extends medially
and slight proximally across the palm, superficial
to the shafts of the third, fourth, and fifth
metacarpals.
3. Digital flexion creases: Each of the medial four digits
have three transverse flexion creases, while the thumb
has two transverse creases:
(a) Proximal flexion crease: It lies at the root of the finger
about 2 cm distal to the metacarpophalangeal (MP)
joint.
(b) Middle flexion crease: It lies over the proximal
interphalangeal (PIP) joint.
(c) Distal flexion crease: It lies on or just proximal to the
distal interphalangeal (DIP) joint.
The digital flexion creases become deeper when the digits are
flexed.
Friction Ridges
The friction skin ridges are present on the finger pads called
fingerprints. These have basic similarities but are not
identical in any two individuals including identical twins.
The four basic types of fingerprints are (Fig. 11.3): (a) arch,
(b) whorl, (c) loop, and (d) composite (combination of first
three). They are produced due to the pull of elastic fibres
within the dermis. The friction ridges prevent the slippage
when grasping the objects. The science of classification and
identification of fingerprints is called dermatoglyphics.
The person with Down syndrome (trisomy-21) usually has
only one transverse palmar crease called simian crease.
Since the fingerprints are not identical in any two
individuals including identical twins, they are used in
criminal investigations to identify criminals.
Proximal digital
flexion crease
Distal transverse
palmar crease
Proximal transverse
palmar crease
Radial
longitudinal
crease
Midpalmar
longitudinal
crease
Distal wrist
crease
Proximal wrist crease
Fig. 11.2 Flexor creases on the palmar aspect of wrist,

palm, and digits.
Fig. 11.3 Types of finger prints: A, arch; B, whorl; C, loop;

D, composite.
Hand
SUPERFICIAL FASCIA OF THE PALM

The superficial fascia of the palm is made up of dense fibrous
bands, which anchor the skin to the deep fascia of the palm.
The superficial fascia of the palm presents two important
features:
1. It contains a subcutaneous muscle, the palmaris brevis
on the ulnar side of the palm, which probably helps to
improve the grip.
2. It thickens to form a superficial metacarpal ligament,
which stretches across the roots of fingers over the digital
nerve and vessels.
Palmaris Brevis Muscle

It is subcutaneous muscle in the superficial fascia of the
medial part of the palm. Morphologically, it represents the
panniculus carnosus.
Origin
From flexor retinaculum and palmar aponeurosis.
Insertion
Into the skin along the medial border of the hand.
Nerve supply
Superficial branch of the ulnar nerve.
Actions
When an object is grasped tightly in the hand, it causes
wrinkling of the medial palmar skin and helps to prevent the
ulnar displacement of the hypothenar eminence.
DEEP FASCIA OF THE PALM

The deep fascia on the palmar aspect of hand is specialized to
form three structures:
1. Flexor retinaculum.
2. Palmar aponeurosis.
3. Fibrous flexor sheaths of digits.
Flexor Retinaculum (Transverse Carpal Ligament)

It is a strong fibrous band which bridges the anterior
concavity of carpus and converts it into an osseofibrous
tunnel called carpal tunnel for the passage of flexor tendons
of the digits.
The flexor retinaculum is rectangular and is formed due
to thickening of the deep fascia in front of carpal bones.
Attachments (Fig. 11.4)
Medially: It is attached to the pisiform and the hook of
hamate.
Laterally: It is attached to the tubercle of scaphoid and the
crest of trapezium.
N.B.
On either side, the flexor retinaculum gives a slip (Fig. 11.4).
A superficial slip on the medial side (called volar carpal
ligament) is attached to the pisiform bone. The ulnar
nerve and vessels pass deep to this slip.
A deep slip on the lateral side is attached to the medial
lip of groove of trapezium, converting it into a osseofibrous
tunnel for the passage of the tendon of flexor carpi
radialis.
Relations
Structures passing superficial to flexor retinaculum
From medial to lateral side these are (Fig. 11.5):
1.
2.
3.
4.
5.
6.
Ulnar nerve.
Ulnar artery.
Palmar cutaneous branch of ulnar nerve.
Tendon of palmaris longus.
Palmar cutaneous branch of median nerve.
Superficial palmar branch of radial artery.
Structures passing deep to the flexor retinaculum (i.e. through

carpal tunnel)
These are as follows (Fig. 11.5):
1. Tendons of flexor digitorum superficialis (FDS).
2. Tendons of flexor digitorum profundus (FDP).
Superficial slip
(volar carpal ligament)
Pisiform
Carpal tunnel
Triquetral
Tubercle
of scaphoid
Scaphoid
Lunate
A
Flexor
retinaculum
Flexor retinaculum
Hamate
Capitate
Carpal tunnel
Deep slip
Crest of
trapezium
Groove of
trapezium
Trapezium
Trapezoid
Fig. 11.4 Attachment of additional medial and lateral slips of the flexor retinaculum. A, at the level of proximal row of carpal
bones; B, at the level of distal row of carpal bones.
139
140
Tendon of palmaris longus

Palmar cutaneous
branch of median nerve
Superficial palmar
branch of radial artery
Palmar cutaneous
branch of ulnar nerve
Ulnar artery
Ulnar nerve
Volar carpal ligament
Median nerve
Tendon of flexor
carpi radialis
Tendon of flexor
pollicis longus
Radial bursa
Tendons of flexor
digitorum superficialis
Tendons of flexor
digitorum profundus
Ulnar bursa
Fig. 11.5 Transverse section of wrist across the carpal tunnel showing structures passing superficial and deep to the flexor
retinaculum.
3. Tendon of flexor pollicis longus (FPL).

4. Median nerve.
Tendon of
palmaris longus
Flexor retinaculum
N.B.
The flexor tendons of fingers (i.e., tendons of FDS and
FDP) are enclosed in a synovial sheath called ulnar bursa.
The tendon of flexor pollicis longus is on the radial side
and enclosed in a separate synovial sheath called radial
bursa.
The tendon of flexor carpi radialis pass through a
separate canal in the lateral part of the flexor retinaculum.
Palmar Aponeurosis
The deep fascia of the palm is thin over thenar and
hypothenar eminences and thick in the central part of the
palm where it forms the palmar aponeurosis.
The palmar aponeurosis (Fig. 11.6) is strong well-defined
part of the deep fascia of the palm which covers the long
flexor tendons and superficial palmar arch. It is triangular in
shape and made up mainly of longitudinal fibres and few
transverse fibres intersecting the former.
Its apex is directed proximally towards the wrist and its
base is directed distally towards the roots of the fingers.
Features
The palmar aponeurosis presents the following features:
1.
2.
3.
4.
Apex.
Base.
Medial border.
Lateral border.
Apex: It is the narrow proximal end of palmar aponeurosis,

which blends with flexor retinaculum. Its superficial fibres
are continuous with the tendon palmaris longus.
Base: It is the broad distal end of palmar aponeurosis. Just
proximal to the heads of metacarpals, the base divides into
Palmaris brevis
Palmar aponeurosis
Digital nerves and

vessels
Fibrous flexor
sheaths
Terminal phalanges
Fig. 11.6 Palmar aponeurosis.
four longitudinal slips, one each of medial four digits. Each

slip, further divides into two slips, which blend with the
fibrous flexor sheaths of the corresponding digits.
The digital nerve and vessels and tendons of lumbrical
emerge through the intervals between the four longitudinal
slips.
Medial border: The medial edge of aponeurosis is continuous with the deep fascia covering the hypothenar muscles
and gives origin to the palmaris brevis.
The medial palmar septum extends inwards from this edge
to the fifth metacarpal. The intermediate palmar septum
extends inwards from near this edge obliquely to the third
metacarpal.
Hand
Lateral border: The lateral edge of the aponeurosis is

continuous with the deep fascia covering the thenar muscles.
Lateral palmar septum extends inwards from this edge to the
first metacarpal.
N.B. Morphologically, palmar aponeurosis represents the
degenerated tendons of palmaris longus muscle.
Functions
1. Helps to improve the grip of hand by fixing the skin.
2. Protects the underlying tendons, nerves, and vessels.
Localized thickening and
contracture of palmar
aponeurosis
Dupuytrens contracture (Fig. 11.7): It is a progressive
fibrosis (interstitial increase in the fibrous tissue) in the
medial part of the palmar aponeurosis. Consequently the
medial part of the aponeurosis may undergo progressive
thickening to form permanent contracture resulting in the
flexion deformity of the little and ring fingers. The ring finger
is most commonly affected. The proximal and middle
phalanges are acutely flexed but distal phalanges remain
unaffected. A surgical fasciectomy is required if the hand
function is grossly impaired.
FIBROUS FLEXOR SHEATHS OF

THE FINGERS (Fig. 11.8)
The deep fascia on the anterior surface of each digit thickens
and arches over the long flexor tendon to form the fibrous
Fig. 11.7 Dupuytrens contracture.
sheath of the finger, which extends from the head of the

metacarpal to the base of distal phalanx.
Attachments
The arched fibrous sheath is attached to the margins of the
phalanges and palmar ligaments of interphalangeal joints.
The proximal end of sheath is open. Here its margins are
continuous with the distal slips of the palmar aponeurosis.
Tendon of flexor
digitorum profundus
Cruciform
parts
Annular/
transverse parts
Palmar ligaments of
IP joints
Fibrous
flexor sheath
Tendon of FDS
Tendon of FDP
Fig. 11.8 Fibrous flexor sheaths of the fingers: A, attachment of the sheath; B, tendons passing through the sheath;
C, arrangement of fibres within sheathcruciate fibres in front of joints and transverse fibres in front of bones (FDS = flexor
digitorum superficialis, FDP = flexor digitorum profundus).
141
142
The distal end of sheath is attached to the palmar surface of

the distal phalanx just distal to the insertion of flexor
digitorum profundus. Thus the sheath along with the
anterior surfaces of the phalanges and palmar ligaments of
interphalangeal joints forms a blind osseofibrous tunnel
through which passes long flexor tendons enclosed in the
digital synovial sheath.
The osseofibrous tunnel of each finger contains a pair of
tendons (tendon of flexor digitorum superficialis and tendon
of flexor digitorum profundus).
The osseofibrous tunnel of thumb contains the tendon of
flexor pollicis longus.
The fibrous sheath is thick over the phalanges, and thin
and lax over the interphalangeal joints to permit flexion.
The annular and cruciform parts (referred to as pulleys by
the clinicians) are thickened reinforcements of the fibrous
flexor sheaths.
Function
The fibrous flexor sheaths hold the tendons in position
during flexion of digits.
Digital synovial
sheaths
Tendon
Mesotendon
Tendons of
FDS and FDP
Synovial sheath
around the
tendon of
flexor pollicis
longus
(radial bursa)
Common synovial
sheath around long flexor
tendons of fingers
(ulnar bursa)
Tendon of FPL
Trigger finger: It is a clinical condition, in which a finger
gets locked in full flexion and can be extended only after
excessive voluntary effort or with the help of the other hand.
When extension begins it occurs suddenly and with a click,
hence the nametrigger finger. This condition is caused by
the presence of a localized thickening of a long flexor
tendon, preventing movement of the tendon within the
fibrous flexor sheath of the digit. When tendon tries to move,
its thickened part is caught in the osseofibrous tunnel
momentarily. This condition can be relieved surgically by
incising the fibrous flexor sheath.
SYNOVIAL SHEATHS OF LONG FLEXOR TENDONS

The synovial sheaths around the long flexor tendons serve
as a lubricating device to prevent their friction, while
moving within the osseofibrous tunnels.
The synovial sheath around the tendon(s) is double
layered consisting of an outer and inner layer with lubricating
synovial fluid between the two layers.
Every tendon within the synovial sheath has a mesotendon
of synovial membrane which conveys vessels to the tendon
(cf. mesenteries of the gut; Fig. 11.9 inset).
Ulnar Bursa (Figs 11.9 and 11.10)

The long flexor tendons of the fingers (four of flexor digitorum
superficialis and four of flexor digitorum profundus), while
passing through the osseofibrous carpal tunnel are enclosed in
a common synovial sheath called ulnar bursa. The tendon
invaginates the sheath from the lateral side.
Fig. 11.9 Synovial sheaths around the long flexor tendons.

Figure in the inset shows two layers of synovial sheath and
mesotendon (FDS = flexor digitorum superficialis, FDP =
flexor digitorum profundus, FPL = flexor pollicis longus).
Digital synovial
sheaths
Ulnar bursa
Radial bursa
Flexor
retinaculum
Fig. 11.10 Ulnar bursa, radial bursa, and digital synovial

sheaths.
Hand
The ulnar bursa extends proximally into the forearm

about a finger breadth (5 cm) proximal to the flexor
retinaculum. Distally it extends in the palm up to the middle
of the shafts of the metacarpal bones.
The distal medial end of ulnar bursa is continuous with
the digital synovial sheath of the little finger.
Vincula
longa
Radial Bursa (Figs 11.9 and 11.10)

The tendon of flexor pollicis longus while passing through
osseofibrous carpal tunnel is enclosed in a synovial sheath
called radial bursa. Proximally it extends into the forearm
about a finger breadth proximal to the flexor retinaculum.
Distally it is continuous with digital synovial sheath of the
thumb.
N.B.
The radial bursa is usually a separate from that of ulnar
bursa but may communicate with ulnar bursa deep to flexor
retinaculum.
Vincula
brevia
Tendon of flexor
digitorum profundus
Fig. 11.11 The long flexor tendons of fingers showing

vincula longa and brevia.
Tenosynovitis of the synovial sheaths of the flexor
tendons: It is the infection and inflammation of the synovial
sheaths of long flexor tendons, which mostly result from
small penetrating wounds caused by pin prick or insertion of
thorn. The infection of digital synovial sheaths results in the
distension of sheath with pus. The digit gets swollen and
becomes very painful due to stretching of sheath by pus.
The infection may extend from digital synovial sheaths to the
palmar spaces.
In case of infection of digital synovial sheaths of little
finger and thumb, the infection may quickly reach into ulnar
and radial bursae due to their continuity, if these bursae are
involved and neglected. The proximal ends of these bursae
may burst and pus may enter into the fascial space of
forearm (space of Parona) between flexor digitorum
profundus anteriorly and interosseous membrane and
pronator quadratus posteriorly.
N.B.
The digital synovial sheath of the little finger is continuous
with the ulnar bursa.
The digital synovial sheath of the thumb is continuous
with the radial bursa.
Parts of long flexor tendons of the index, middle, and
ring fingers between the ulnar bursa and digital synovial
sheaths are devoid of synovial sheaths.
Vincula Longa and Vincula Brevia (Fig. 11.11)

As the tendons lie within the fibrous flexor sheaths, they are
connected to the phalanges by the thin bands of connective
tissue, called vincula. In each digital sheath, there are five
vinculatwo short and three long. The short ones are called
vincula brevia and long ones vincula longa. The vincula
brevia are small triangular bands attached to the palmar
aspect of the IP joints and distal part of adjoining proximal
phalanx. The vincula longa are long, narrow band, which
extend from the dorsal aspect of the tendon to the proximal
part of the palmar surface of the proximal phalanx. The
blood vessels reach the tendons through these vincula.
Vincula
longa
Tendon of flexor
Digital Synovial Sheaths (Figs 11.9 and 11.10)

The flexor tendons of digits while passing through the fibrous
flexor sheaths are enclosed in the synovial sheath. The digital
synovial sheath extends from head of metacarpals to the distal
phalanges of the digits.
Functions
Function of the ulnar and radial bursae, and digital synovial
sheaths is to allow the long tendons of digits to move freely/
smoothly with minimum friction beneath flexor retinaculum and fibrous flexor sheaths.
Vincula
brevia
INTRINSIC MUSCLES OF THE HAND

These are short muscles whose origin and insertion is
confined within the territory of the hand. They are
responsible for skilled movements of the hand and also
help the hand in adjusting for proper gripping. There are
20 intrinsic muscles in hand. They have small motor units;
hence can act with precision to carry out skilled
movements.
The intrinsic muscles of the hand are arranged into the
following five groups:
1.
2.
3.
4.
5.
Thenar muscles.
Adductor of thumb.
Hypothenar muscles.
Lumbricals.
Interossei.
143
144
Thenar Muscles (Fig. 11.12)

They are three in number, viz.
1. Abductor pollicis brevis.
2. Flexor pollicis brevis.
3. Opponens pollicis.
Relationship
1. Abductor pollicis brevis lies laterally.
2. Flexor pollicis brevis lies medially.
3. Opponens pollicis lies deep between the above two
muscles.
Features
1. They form thenar eminence of palm of the hand.
2. They are chiefly responsible for opposition of thumb.
3. All of them are supplied by the recurrent branch of the
median nerve (C8, TI).
N.B. The actions of thenar muscles are indicated by their
names to some extent; but they all are involved in opposition
providing pincer-like grip between the thumb and index
finger.
Hypothenar Muscles (Fig. 11.12)

They are also three in number, viz.
1. Abductor digiti minimi.
2. Flexor digiti minimi.
3. Opponens digiti minimi.
Some authorities also consider palmaris brevis (see page
139) as one of the hypothenar muscles.
Relationship
1. Abductor digiti minimi lies medially.
2. Flexor digiti minimi lies laterally.
3. Opponens digiti minimi lies deep to the above two muscles.
Features
1.
They form hypothenar eminence of the palm of the

hand.
2. All of them are supplied by the deep branch of ulnar
nerve. The origin, insertion, and actions of the thenar
and hypothenar muscles are presented in Table 11.1.
N.B.
The flexor pollicis brevis has dual nerve supply: superficial
head by the median nerve and deep head by the deep
branch of the ulnar nerve.
Tendons of insertion of the flexor digiti minimi along with
the abductor digiti minimi on the medial side of the base
of first phalanx contain a sesamoid bone.
Adductor Pollicis Muscle (Fig. 11.13)

This fan-shaped muscle is located deep in the palm in
contact with metacarpal and interossei. It consists of two
heads: (a) oblique and (b) transverse.
Origin
1. Oblique head arises from anterior aspects of capitate
bone and bases of second and third metacarpal bones
forming a crescentic shape.
2. Transverse head arises from ridge on distal two-third of
the anterior surface of the shaft of the third metacarpal.
Insertion
Into the medial side of the base of proximal phalanx of the
thumb.
Nerve supply
Deep branch of the ulnar nerve (C8, TI).
Actions
Adduction of the thumb to provide power to the grip.
N.B.
The tendons of insertion of adductor pollicis on the
medial side of the base of proximal phalanx of the thumb
contain a sesamoid bone.
The deep palmar arch and deep branch of ulnar nerve
pass between the two heads of adductor pollicis.
Clinical testing (Foments sign)

Give the patient a thin book and ask him to grasp it firmly
between the thumbs and index fingers of both hands. If the
muscle is healthy and acting normally, the thumbs will be
straight. But if the muscle is paralyzed and not acting, the thumbs
are flexed at IP joints (Fig. 13.4). This occurs because when
adductors are not acting, flexor pollicis compensates for it.
Lumbrical Muscles (Fig. 11.14)

There are four lumbrical muscles and numbered first,
second, third, and fourth from lateral to medial side. They
are small slender muscles one for each digit. They are named
lumbricals because of their elongated worm-like shape
(L. lumbrical earthworm).
Origin
1. Lumbricals 1 and 2: From lateral side of lateral two
tendons of the flexor digitorum profundus.
2. Lumbricals 3 and 4: From adjacent sides of medial three
tendons of the flexor digitorum profundus.
Insertion
The tendons cross the radial side of metacarpophalangeal
(MP) joints to be inserted into the lateral side of dorsal
digital expansion of the corresponding digit from second to
fifth.
146
Table 11.1 Origin, insertion, and actions of the thenar and hypothenar muscles
Muscles
Origin
Insertion
Action
Thenar muscles
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Tubercle of scaphoid
Crest of trapezium
Flexor retinaculum
Lateral side of base of the proximal

phalanx of thumb
Abduction of thumb
Superficial head from the

distal border of the flexor
retinaculum
Deep head from trapezoid
and capitate bones
Lateral side of the base of the

proximal phalanx of thumb
Flexion of thumb
Flexor retinaculum crest of

trapezium
Lateral border and adjoining lateral

half of the palmar surface of the first
metacarpal bone
Opposition of thumb
Deepens the hollow of palm
Hypothenar muscles
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Pisiform bone
Tendon of flexor carpi
ulnaris
Ulnar side of the base of the proximal Abduction of little finger

phalanx of little finger
Flexor retinaculum
Hook of hamate
Ulnar side of base of the proximal

phalanx of little finger along with
tendon of abductor digiti minimi
Flexion of little finger
Flexor retinaculum
Hook of hamate
Medial surface of the shaft of 5th

metacarpal bone
Oblique head
Adductor
pollicis
Transverse head
Sesamoid bone
Insertion
Medial side of
base of proximal
phalanx
Fig. 11.13 Origin and insertion of the adductor pollicis muscles.
Opposition of the tip of little

finger with the tip of thumb
Deepens the hollow of palm
Origin
1. Oblique head from
capitate and bases of
2nd and 3rd metacarpals
2. Transverse head from

shaft of 3rd metacarpal
Hand
Table 11.3 Differences between the palmar and dorsal interossei

Features
Palmar interossei
Dorsal interossei
Location
On the palmar surface between the metacarpals
Between the metacarpals
Type
Unipennate
Bipennate
Origin
From palmar aspects of the metacarpals
From side of metacarpals
Action
Adduction of digits
Abduction of digits
1. Superficial palmar branch of the radial artery (most

common).
2. Radialis indicis artery.
3. Princeps pollicis artery.
Branches
1. Three common palmar digital arteries go to the
interdigital clefts between the fingers and each divides
into two proper digital arteries, which supply their
adjacent sides. In the interdigital clefts, they are joined
by the palmar metacarpal arteries.
2. One proper digital artery runs along the medial side of
the little finger which it supplies.
3. Cutaneous branches to the palm, which supply the skin
and superficial fascia of the palm.
Relations
Superficial: Palmar aponeurosis.
Deep: 1. Long flexor tendons of FDS and FDP.
2. Lumbricals.
3. Digital branches of the median and ulnar nerves.
Radial artery
Superficial palmar
branch of
radial artery
Princeps
pollicis artery
Ulnar artery
Deep palmar
branch of
ulnar artery
Deep palmar
arch
Superficial
palmar arch
Palmar
metacarpal
artery
Radialis indicis
artery
Fig. 11.17 Superficial and deep palmar arterial arches.
Surface Anatomy
The superficial palmar arch lies across the centre of the palm
at the level of the distal border of the fully extended thumb.
Deep Palmar Arch (Fig. 11.17)

The deep palmar arch is the direct continuation of radial
artery. The arch is completed medially (at the base of the
fifth metacarpal) by anastomosing with the deep palmar
branch of the ulnar artery.
The radial artery enters the palm from dorsal aspect of the
hand by passing between the two heads of first dorsal
interosseous muscle. Immediately after entering the palm,
the radial artery gives off two branches: arteria radialis indicis
and arteria princeps pollicis. In the palm, it passes between
the two heads of adductor pollicis.
Branches
1. Three palmar metacarpal arteries, which join the
common palmar digital arteries, the branches of the
superficial palmar arch.
2. Three perforating arteries, which pass through the 2nd,
3rd, and 4th interosseous spaces to anastomose with
dorsal metacarpal arteries.
3. Recurrent branch/branches run proximally in front of
carpus to end in the palmar carpal arch.
Relations
Deep:
(a) Proximal parts of shafts of the metacarpals.
(b) Interosseous muscles.
Superficial:
(a) Long flexor tendons of the fingers.
(b) Lumbricals.
N.B. The deep branch of the ulnar nerve lies in the concavity
of deep palmar arch.
Surface Anatomy
The deep palmar arch lies about 1 cm proximal to the
superficial palmar arch.
The differences between the superficial and deep palmar
(arterial) arches are given in Table 11.4.
149
150
Table 11.4 Differences between the superficial and deep palmar arches
Deep palmar arch
Formation
By anastomosis between direct continuation of the ulnar By anastomosis between direct continuation of the
artery (i.e., superficial palmar branch) with the small
radial artery with the small deep palmar branch of the
superficial branch of the radial artery
ulnar artery
Location
Superficial to long flexor tendons
Branches
Deep to long flexor tendons
Three common palmar digital arteries

One proper digital artery
Cutaneous branches
Laceration of palmar arterial arches: The lacerated
wounds of palmar arterial arches usually cause profuse and
uncontrollable bleeding. The compression of brachial artery
against humerus is the most effective method to control the
bleeding.
The ligation or clamping of the radial artery or ulnar artery
or both proximal to wrist fails to control the bleeding because
of connections of these arches with the palmar and dorsal
carpal arches.
NERVES IN THE PALM OF THE HAND

There are two nerves in the palm of the hand, viz.
1. Ulnar nerve.
2. Median nerve.
N.B. The ulnar nerve is the main motor nerve of the hand,
whereas median nerve is the main sensory nerve of the
hand.
Ulnar Nerve (Figs 11.18 and 11.19)

The ulnar nerve enters the palm by passing superficial to the
flexor retinaculum between the pisiform bone and ulnar
artery. At the distal border of flexor retinaculum it divides
into superficial and deep terminal branches.
Superficial Branch
It enters the palm deep to palmaris brevis, which it supplies
and then divides into digital branches. The digital nerves
supply the skin of the medial 1 finger. The digital nerves
cross over the tips of digits and supply the skin on the
dorsum of distal phalanges. The superficial branch of the
ulnar nerve is accompanied by the superficial branch of the
ulnar artery.
Deep Branch
It dips in the interval between abductor digiti minimi and
flexor digiti minimi muscles, then pierces opponens digiti
minimi to reach the deep part of the palm. It turns laterally
Three palmar metacarpal arteries

Three perforating arteries
Recurrent branches
within the concavity of the deep palmar arch to end by

supplying the adductor pollicis.
The deep branch supplies:
Muscular branches to
three hypothenar muscles,
adductor pollicis,
four dorsal interosseous muscles,
four palmar interosseous muscles, and
medial two lumbricals.
Articular branches to intercarpal, carpometacarpal, and
intermetacarpal joints.
The distribution of ulnar nerve in the hand is summarized in

Table 11.5.
N.B. The ulnar nerve supplies all the intrinsic muscles of the
hand (except thenar muscles and lateral two lumbricals),
which are concerned with fine movements of the hand as
performed by musicians. Hence ulnar nerve is also termed
musicians nerve.
Ulnar canal syndrome/Guyons tunnel syndrome: It is
clinical condition, which occurs due to compression of the
ulnar nerve in Guyons canal* at wrist. Clinically it presents
as:
(a) Hypoesthesia in medial 1 fingers, and
(b) Weakness of intrinsic muscles of hand.
*Ulnar tunnel/Guyons canal is an osseofibrous tunnel formed by
the pisohamate ligament bridging the concavity between pisiform
bone and hook of hamate.
Median Nerve (Fig. 11.19)

The median nerve enters the hand by passing through the
carpal tunnel, (i.e., deep to flexor retinaculum) along with
nine tendons (four each of FDS and FDF and one of FPL).
Just after emerging from carpal tunnel it divides into lateral
and medial divisions.
Hand
Tendon of flexor
carpi ulnaris
Ulnar artery
Dorsal cutaneous branch

for medial skin of the dorsum
of hand and 1 digits
Pisiform bone
Palmar cutaneous branch

to medial skin of palm
Superficial branch
Deep branch
Palmaris brevis
Adductor pollicis
Superficial terminal branch

to palmar aspect of 1 digits
Flexor pollicis
brevis (often)

4 dorsal interossei
3 palmar interossei

Medial, 2 lumbricals
Fig. 11.18 Course and distribution of the ulnar nerve in hand.
Median nerve
Ulnar nerve
Deep branch
Superficial branch
Recurrent branch
Nerve to
palmaris brevis
Median
nerve
Ulnar nerve
Nerve to 1st
lumbrical
Nerve to 2nd
lumbrical
Fig. 11.19 Median and ulnar nerves in hand: A, branches; B, areas of sensory innervation of the palmar aspect of the hand.
Lateral division gives off:

(a) recurrent branch, which curls upwards to supply thenar
muscles (e.g., abductor pollicis brevis, flexor pollicis
brevis, and opponens pollicis) and
(b) three proper palmar digital branches, which provides
sensory innervation to thumb and lateral side to the
index finger. The digital branch to the index finger sends
a twig to the first lumbrical.
Medial division gives off:
Two common digital nerves, which provides sensory
innervation to the medial side of the index finger, middle
finger, and lateral side of the ring finger. The lateral common digital nerve sends a twig to second lumbrical.
The distribution of median nerve in hand is summarized
in Table 11.6.
FASCIAL SPACES OF THE HAND

By virtue of the arrangement of various fascia and fascial
septa, many fascial spaces are formed in the region of the
hand. Normally they are potential spaces filled with loose
connective tissue but they become obvious only when
fluid or pus collects in them. These spaces are of great sur-
151
Hand
Midpalmar Space (Fig. 11.21)

The triangular midpalmar space is located under the medial
half of hollow of the palm.
Boundaries
Anterior: From superficial to deep, it is formed by:
1. Palmar aponeurosis.
2. Superficial palmar arch.
3. Digital nerve and vessels supplying medial
3 fingers.
4. Ulnar bursa enclosing flexor tendons of
medial three fingers.
5. Medial three (2nd, 3rd, and 4th) lumbricals.
Posterior: Fascia covering interossei and medial three
metacarpals.
Lateral:
Intermediate palmar septum extending obliquely
from near the medial edge of the palmar
aponeurosis to the third metacarpal bone. This
septum separates the midpalmar space from the
thenar space.
Medial:
Medial palmar septum extending from medial
edge of palmar aponeurosis to the fifth metacarpal.
This septum separates the midpalmar space from
hypothenar space occupied by the hypothenar
muscles.
Proximal: Midpalmar space is continuous with the forearm
space of Parona.
Distal:
Midpalmar space is continuous with the medial
three web-spaces through medial three lumbrical
canals.
Intermediate palmar septum

Palmar aponeurosis
N.B.
Web spaces: The web space is a subcutaneous space in
each interdigital cleft and is filled with loose areolar tissue. It
contains lumbrical tendon, interosseous tendon, digital
nerve, and vessels.
The web space extends from the free margin of the web,
as far proximally as the level of transverse metacarpal
ligaments.
Infection of midpalmar space: The ulnar bursa is
considered as the inlet for infection and lumbrical canals as
the outlets of infection in midpalmar space. The pus form
this space is drained by incisions in the medial two web
spaces.
Thenar Space (Fig. 11.21)

The triangular thenar space is located under the outer half of
the hollow of the palm.
Boundaries
Anterior: From superficial to deep, it is formed by:
1. Palmar aponeurosis (lateral part).
2. Digital nerve and vessels of lateral 1 digits.
3. Radial bursa enclosing tendon of flexor
pollicis longus.
4. Flexor tendons of the index finger.
5. First lumbrical.
Lateral:
Lateral palmar septum extending from lateral edge
of palmar aponeurosis to the first metacarpal.
Lateral palmar septum

Flexor tendon to index finger
Tendon of flexor
pollicis longus
Flexor tendons to
middle, ring and little fingers
Medial palmar septum
Thenar muscles
First metacarpal
Hypothenar muscles
Thenar space
Fifth metacarpal
Adductor pollicis
Midpalmar space
Dorsal subcutaneous space

Dorsal subaponeurotic space
Fig. 11.21 Cross section of the hand showing palmar spaces and spaces on the dorsum of the hand.
153
154
Epiphysis of terminal phalanx
Terminal phalanx
Nail
Skin
Pulp space
Thenar space
Midpalmar space
Palmar
aponeurosis
Long flexor
tendon
Deep fascia
Fibrous septa
Digital artery
Fig. 11.23 Pulp space of the finger.

Adductor pollicis
Fig. 11.22 Midpalmar and thenar spaces of the hand and

their surface projections in the palm.
Medial:
Intermediate palmar septum.
Posterior: Fascia covering the transverse head of adductor
pollicis.
Proximal: The space is limited by the fusion of anterior and
posterior walls in the carpal tunnel.
Distal:
The space communicates with the first web space
through the first lumbrical canal.
Infection of thenar space: The infection may reach the
thenar space from infected radial bursa or synovial sheath
of the index finger.
The pus from thenar space is drained by an incision in the
first web space (web space of the thumb).
The midpalmar and thenar spaces and their surface

projection in the palm are shown in Figure 11.22.
Features
1. The space is traversed by numerous fibrous septa
extending from skin to the periosteum of the terminal
phalanx, dividing it into many loculi.
2. The deep fascia of pulp of each finger fuses with the
periosteum of terminal phalanx distal to the insertion of
long flexor tendon.
3. The digital artery that supplies the diaphysis of phalanx
runs through this space. The epiphysis of distal phalanx
receives its blood supply proximal to the pulp space.
Pulp space infection: Being the most exposed parts of the
digits the pulp spaces are prone for infection. An abscess in
the pulp-space is called whitlow or felon. The rising tension
in the pulp space causes severe throbbing pain. The pus
from pulp space is drained by a lateral incision, opening all
loculi and avoiding tactile skin sensation on the front of the
finger.
If neglected, the whitlow may lead to avascular necrosis
of distal four-fifth of the terminal phalanx due to occlusion of
digital artery as result of pressure. The proximal one-fifth
phalanx (i.e., epiphysis) is not affected because the branch
of digital artery supplying it does not traverse the pulp
space.
PULP SPACES OF THE DIGITS (Fig. 11.23)
Dorsal Surfaces
These are described on p. 172.
The pulp spaces of the digits are subcutaneous spaces on the

palmar side of tips of the fingers and thumb. The pulp space
is filled with subcutaneous fatty tissue.
Space of Parona (Forearm space; Fig. 11.24)

It is merely a fascial interval underneath the flexor tendons
on the front of distal part of the forearm.
Boundaries
Boundaries
Anterior: (a) Tendon of flexor digitorum profundus and
flexor digitorum superficialis surrounded
by a synovial sheath (ulnar bursa).
Superficially: Skin and superficial fascia.

Deeply: Distal two-third of distal phalanx.
Hand
Long flexor tendon

Ulnar bursa
Paronas space
Pronator
quadratus
Digital synovial
shealh
Midpalmar
F
space
Fig. 11.24 Forearm space (Paronas space) as seen in

section along the long axis of the hand.
(b) Tendon of flexor pollicis longus surrounded

by a synovial bursa (radial bursa).
Proximal: Proximally, it is continuous with the intermuscular spaces of the forearm.
Distal:
Distally it reaches the level of wrist.
Lateral:
Outer border of the forearm.
Medial:
Inner border of the forearm.
The forearm space (Paronas space) becomes infected from
infected ulnar bursa. Pus collects behind the long flexor
tendons.
Surgical Incisions on the Front of Wrist and

Hand (Fig. 11.25)
The surgical incisions in the palm should be well-planned
and given carefully to avoid contractures:
Incisions should be parallel to major skin creases of the

hand as far as possible.
An incision should not cross the skin crease at a right angle.
Guidelines for some incisions are as follows (Fig. 11.25):

To drain abscess of the thenar space, a vertical incision is

given in first web space (A).
To drain abscess from midpalmar space, small vertical
incision should be given in the medial two web spaces
(B).
To drain abscess from ulnar bursa, incision should be given
along the radial margin of hypothenar eminence (C).
To drain abscess from radial bursa, incision should be
given along the medial margin of thenar eminence (D).
To drain pus from digital synovial sheath, vertical incisions
should be given along the side of proximal and middle
phalanges (E).
To drain pus from pulp space, vertical incision should be
given along the sides of pulp (F).
To drain pus from space of Parona, vertical incisions
should be given on the distal part of forearm (G).
A
C
Fig. 11.25 Incisions on the front of wrist and hand for

draining abscess from: A, thenar space; B, midpalmar space;
C, ulnar bursa; D, radial bursa; E, digital synovial sheath;
F, pulp space; G, space of Parona.
DORSUM OF THE HAND

Surface Landmarks
1. Knuckles, the bony prominences at the junction of hand
and digits, which become visible prominently when a fist
is made. They are produced by the heads of metacarpals.
2. Anatomical snuff-box, a triangular depression, which
appears on the dorsolateral aspect of the hand when the
thumb is hyperextended. The pulsations of radial artery
can be felt in this box. The beginning of cephalic vein
can also be seen at this site. The tendon of extensor
pollicis longus forming its posterior boundary and
tendons of abductor pollicis longus and extensor pollicis
brevis forming its anterior boundary are clearly visible.
3. Extensor tendons of fingers stand out clearly when the
wrist is extended and digits are abducted. These tendons
are not visible far beyond knuckles because they flatten
here to form extensor expansions.
4. Dorsal venous network is clearly visible and forms the
prominent feature of the dorsum of hand.
5. Base of first metacarpal (thumb) can be readily felt in
the angle between the tendons of abductor pollicis
longus and extensor pollicis longus.
6. Whole of the radial border and most of the dorsal
surface of the second (index) metacarpal can be readily
155
156
felt. Its base forms the prominence of the back of the

hand.
N.B. The dorsal surfaces of metacarpals of the middle, ring,
and little fingers are obscured by the extensor tendons.
SKIN ON THE DORSUM OF THE HAND

The skin on the dorsum of the hand is thin and loose when
the hand is relaxed. The hairs are present on the dorsum of
the hand and on the proximal parts of the digits, especially in
males.
Superficial Fascia
The superficial fascia on the dorsum of the hand contains
dorsal venous arch, cutaneous branches of the radial nerve,
and dorsal cutaneous branch of the ulnar nerve (Fig. 11.20):
1. Dorsal venous arch is the network of veins on the dorsum
of the hands. It is already described in Chapter 7, P. 86.
2. Superficial radial nerve (terminal cutaneous branch of
the radial nerve) is described on page 158.
3. Dorsal cutaneous branch of the ulnar nerve is described
on page 158.
Deep Fascia
The deep fascia on the back of the wrist is thickened to
form thick fibrous bandthe extensor retinaculum, which
holds the extensor tendons in place (for details see pages 120
and 122).
EXTENSOR TENDONS ON THE DORSUM OF THE HAND
sides like a hood and fuses anteriorly with the fibrous flexor
sheath. The tendons of lumbricals and interossei are inserted
into this expansion. The expansion narrows as the tendons of
lumbricals and interossei converge towards it on the dorsum of
the proximal phalanx and splits into three slips. The central
slip is inserted into the base of the middle phalanx and the
lateral slips to the base of terminal phalanx.
N.B.
The dorsal digital expansion forms a functional unit to
coordinate the actions of long extensors, long flexors,
lumbricals and interossei on the digit.
On the index finger and little finger, the expansion is
strengthened by extensor indicis and extensor digiti
minimi, respectively, which blends with it.
Mallet
finger/baseball
finger/cricketers
finger
(Fig. 11.26): The insertion of extensor tendon into the base
of the terminal phalanx may be torn by a forceful blow on
the tip of the finger, which causes sudden and strong
flexion of the phalanx. Occasionally, small flakes of the
bone may be avulsed. Consequently the distal phalanx
assumes a flexed position with swan neck deformity and
voluntary extension is impossible. This condition
commonly occurs in cricketers and baseball players.
Boutonnire (button-hole) deformity (Fig. 11.27): It is
opposite to mallet finger deformity. It is characterized by
flexion of proximal interphalangeal (PIP) joint and
hyperextension of distal phalanx. It occurs when the flexed
PIP joint pokes through the extensor expansion following
rupture of its central portion of dorsal digital expansion
due to a direct end on trauma to the finger.
The extensor tendons on the dorsum of the hand are as

follows:
1. Tendons of the thumb: They are three in number; one
for each bone of the thumb:
(a) Tendon of abductor pollicis longus (APL) is inserted
on the base of 1st metacarpal.
(b) Tendon of extensor pollicis brevis (EPB) is inserted
on the base of proximal phalanx.
(c) Tendon of extensor pollicis longus (EPL) is inserted
on the base of distal phalanx.
2. Tendons of extensor digitorum: These are four in
number, which diverge across the dorsum of the hand,
where they are usually connected to one another by
three oblique fibrous intertendinous bands. The tendons
are united in such a way as to form with deep fascia an
aponeurotic sheath, which is attached to the borders of
the second and fifth metacarpals.
DORSAL DIGITAL EXPANSIONS (Fig. 11.16)

Each tendon of extensor digitorum expands over the
metacarpophalangeal joint to cover its dorsal aspect and
Torn extensor
tendon
Fig. 11.26 Mallet finger with swan neck deformity.

Rupture of central portion of
extensor expansion
Extensor expansion
Flexed PIP
Fig. 11.27 Boutonniere (button-hole) deformity. Note

proximal interphalangeal (PIP) joint is poking through the
extensor expansion.
Hand
Tendon of extensor
pollicis longus
First metacarpal
Radial artery
Tendon of extensor
pollicis brevis
Tendon of abductor
pollicis longus
Tendon of extensor
pollicis longus
Tendon of extensor
pollicis brevis
Tendon of abductor
pollicis longus
radial nerve
Cutaneous
branches of
superficial
radial nerve
Cephalic vein
Extensor
retinaculum
Radial artery
Cephalic vein
Fig. 11.28 Boundaries and contents of the anatomical

snuffbox (S = scaphoid).
ANATOMICAL SNUFF-BOX (Figs 11.28 and 11.29)

The anatomical snuff-box is an elongated triangular
depression seen on the lateral side of the dorsum of hand
when the thumb is hyperextended.
Boundaries (Fig. 11.28)

Anterolaterally:
1. Tendon of abductor pollicis longus.
2. Tendon of extensor pollicis brevis.
Posteromedially: Tendon of extensor pollicis longus.
Floor: It is formed by
1. scaphoid and
2. trapezium.
Roof: It is formed by
1. skin and
2. superficial fascia.
Contents: Radial artery.
Structures crossing the roof deep to skin (Fig. 11.29):
1. Cephalic vein, from medial to lateral side.
2. Terminal branches of the superficial radial nerve, from
lateral to medial side.
Fig. 11.29 Structures crossing the roof of anatomical

snuffbox.
Clinical significance of anatomical snuff box:
The pulsations of radial artery can be felt in the anatomical
box.
The tenderness in the anatomical box indicates fracture of
scaphoid bone.
The cephalic vein at this site is often used for giving
intravenous fluids.
The superficial branches of the radial nerve can be rolled
over the tendon of extensor pollicis longus.
ARTERIES ON THE DORSUM OF THE HAND

1. Radial artery: The radial artery on leaving the forearm,
winds round the radial side of the wrist lying on the
radial collateral ligament. It passes through anatomical
box, on the dorsal surface of scaphoid and trapezium
and then passes forward into the palm of the hand by
passing between the proximal ends of first and second
metacarpals and two heads of the first dorsal interosseous muscle.
2. Dorsal carpal arch: It is an arterial arch lying on the
dorsal aspect of the carpus. It is formed by the posterior
carpal branches of the radial and ulnar arteries,
respectively.
157
158
The dorsal carpal arch gives off three dorsal metacarpal

arteries, each of which terminates by dividing into two
digital arteries. The digital arteries from three metacarpal
arteries supply medial 3 fingers.
3. Dorsal digital artery: The dorsal digital artery for thumb
(princeps pollicis artery) and dorsal digital artery for
radial side of the index finger (radialis indicis artery)
arise from radial artery just distal to the origin of its
dorsal carpal branch.
Nerves of the Dorsum of the Hand (Fig. 11.27)

The nerves of the dorsum of the hand are two, viz.
1. Superficial radial nerve (superficial cutaneous branch of
the radial nerve).
2. Dorsal cutaneous branch of the ulnar nerve.
Superficial Radial Nerve
The part of radial nerve in hand is its superficial terminal
branch called superficial radial nerve.
About 7 cm above the wrist, the superficial radial nerve
passes laterally deep to the tendon of brachioradialis, pierces
the deep fascia on the dorsal aspect of the wrist to reach the
dorsum of the hand and immediately divides into 4 or 5
dorsal digital nerves, which cross the roof of anatomical
snuff-box and supply the skin over the lateral two-third of
the dorsum of hand and dorsal aspects of lateral 3 digits
except the skin over their distal phalanges.
Dorsal Cutaneous Branch of Ulnar Nerve
It arises from ulnar nerve about 5 cm about the wrist. On
reaching the hand, it divides into two branches which
supply the skin of the medial 1 finger except their distal
phalanges.
1. Dorsal subcutaneous space.

2. Dorsal subaponeurotic space.
Dorsal subcutaneous space: It lies deep to skin on the
dorsum of the hand.
Dorsal subaponeurotic space: The extensor tendons on the
dorsum of hand along with deep fascia of the dorsum of
hand forms an aponeurotic sheet which is attached to the
borders of the 2nd and 5th metacarpals.
The space between dorsal surface of the medial four
metacarpals and interosseous muscles anteriorly and
aponeurotic sheet (vide supra) posteriorly is called dorsal
subaponeurotic space.
The dorsal subaponeurotic space is limited proximally
at the bases of metacarpals and distally at the
metacarpophalangeal joints by fibrous partitions.
Infection of subcutaneous space: The infection of
subcutaneous space is uncommon but sometimes it may
get infected after injury over the knuckles. Collection of
pus in this space produces large swelling due to looseness
of the skin. The pus points through skin and can be
drained by incision given at the pointing site.
Infection of subaponeurotic space: The septic infection
of subaponeurotic space is generally primary, following
wounds on the dorsum of the hand. It may, however, get
involved secondarily to the infection of the midpalmar
space. The pus collected in the subaponeurotic space is
limited proximally at the bases of metacarpal bones and
distally at the metacarpophalangeal joints. On each side,
it is limited opposite the borders of second and fifth
metacarpal bones. To drain the pus from this space,
incisions are made in the aponeurosis between the
tendons distally. Alternatively, two incisions may be made,
one on the radial side and one along the ulnar side of
extensor tendons.
Sensory innervation of the hand

Palmar aspect (Fig. 11.19)
1. Medial one-third of palm and medial 1 digit except
dorsal aspect of their distal phalanges by the ulnar nerve.
2. Lateral two-third of palm and lateral 3 digits including
dorsal aspect of their distal phalanges by the median
nerve.
Dorsal aspect (Fig. 11.20)
1. Lateral two-third of dorsum of the hand and lateral 3
digits except distal phalanges by the radial nerve.
2. Medial one-third of dorsum of the hand and medial 1
digit except their distal phalanges by the ulnar nerve.
SPACES ON THE DORSUM OF THE HAND

These are two potential spaces on the dorsum of the hand
(Fig. 11.29), viz.
ARCHES OF THE HAND

Like foot, the hand also has arches. The hand is composed of
a series of three flexible bony arches. Their preservation
following an injury is of supreme functional importance to
the hand.
The arches of the hand are as follows:
1. Transverse carpal arch: It is formed by the concavity of
the carpus with flexor retinaculum stretching between
its pillars.
2. Transverse metacarpal arch: It is formed by the heads of
the metacarpal bones, which are bound together by the
deep metacarpal ligaments.
3. Longitudinal arch: It is formed by the palmar concavity
of the metacarpals and normal slightly flexed posture of
the digits.
Hand
FUNCTION OF ARCHES
The arches of the hand provide room for grasping objects in
the hollow of palm.
The more accentuated the arches are, the more secure is
the grip. The thenar and hypothenar muscles and palmaris
brevis play an important role in providing adjusting power
of the arches.
Abnormalities of arches of the hand: The disturbances
of palmar arches result in flat hand with impairment of
gripping power. The flattening of carpal arch seriously
affects the gripping power of the thumb. It occurs due to
surgical division of flexor retinaculum or injury to the
carpus.
159
CHAPTER
12
Joints and Movements of

the Hand
JOINTS OF WRIST, HAND, AND FINGERS

The hand is the region of the upper limb distal to the wrist
joint. It consists of three parts: (a) wrist, (b) metacarpus, and
(c) digits.
The study of joints of hand is essential to understand the
various movements of the hand. Of these, radio-carpal
(wrist) and first carpometacarpal joints need to be studied in
detail as they execute wide range of movements.
WRIST JOINT (RADIO-CARPAL JOINT; Fig. 12.1)
Articular surfaces
1. Proximal articular surface is formed by inferior
surface of the lower end of radius and inferior surface
of the triangular articular disc of inferior radio-ulnar
joint.
This articular surface is almost elliptical in shape and
concave from side to side.
2. Distal articular surface is formed by the proximal
surfaces of scaphoid, triquetral, and lunate bones. It is
smooth and convex.
N.B.
Type
The wrist joint is a synovial joint of ellipsoid variety between
lower end of radius and carpus.
Although wrist joint is an articulation between forearm

and hand, the medial bone of forearm the ulna is
excluded from this articulation by an articular disc.
Radius
Articular disc
Ulna
Ulna
Wrist joint
Radius
Radial collateral
ligament
Sca
Lun
Tri
Midcarpal
joint
Tr
First
carpometacarpal joint
Articular disc
Cap
Ham
Tz
First
metacarpal
Fifth
metacarpal
B
Scaphoid
Lunate
Triquetral
Fig. 12.1 Coronal section through wrist region: A, schematic diagram; B, as seen in magnetic resonance imaging, showing
wrist joint, midcarpal joint, intercarpal joints, carpometacarpal joints. (Source B: Fig. 7.91C, Page 710, Gray's Anatomy for
Students, Richard L Drake, Wayne Vogl, Adam WM Mitchell. Copyright Elsevier Inc. 2005, All rights reserved.)
Median nerve
Tendon of flexor
pollicis longus
Palmaris longus
Tendons of flexor
Tendons of flexor
digitorum profundus
Radial artery
Ulnar artery
Ulnar nerve
Dorsal cutaneous
branch of ulnar nerve
L
Radial articular
surface
Extensor carpi
radialis longus

Tendon of extensor indicis
Extensor carpi radialis brevis

Basilic vein
Tendons of extensor digitorum

Cephalic vein
Fig. 12.3 Relations of the right wrist joint (A = articular disc, M = medial (ulnar) collateral ligament, L = lateral (radial)
collateral ligament).
2. Anterior interosseous artery.

3. Anterior interosseous nerve.
Lateral
rotation at wrist is compensated by the movements of

pronation and supination of the forearm.
The wrist complex consists of radio-carpal joint and
midcarpal joint.
1. Radial artery (across the radial collateral ligament).

2. Tendon of abductor pollicis longus (APL).
3. Tendon of extensor pollicis brevis (EPB).
The movements at the wrist joint and muscles producing

them are listed in Table 12.1 (also see Flowchart 12.1).
Medial: Dorsal cutaneous branch of ulnar nerve.
Table 12.1 Movements at the wrist joint and muscles

producing them
Movements
It is a biaxial joint and permits the following movements:
1.
2.
3.
4.
5.
Flexion.
Extension.
Abduction.
Adduction.
Circumduction.
Flexion and extension occur along the transverse axis, and

abduction and adduction occur along the anteroposterior
axis.
N.B.
The movements at the wrist joint are usually associated
with movements at the midcarpal joint (joint between the
proximal and distal rows of carpal bones). The wrist and
midcarpal joints together are considered as link joint.
Rotation is not possible at the wrist joint because the
articular surfaces are ellipsoid in shape. The lack of
Movement
Muscles
Flexion (upward
bending of the wrist)
Extension (backward
Abduction (lateral
Adduction (medial
Flexor carpi radialis (FCR)

Flexor carpi ulnaris (FCU)
Palmaris longus (PL)
Extensor carpi radialis longus
(ECRL)
(ECRB)
Extensor carpi ulnaris (ECU)
Flexor carpi radialis (FCR)
(ECRL)
(ECRB)
Flexor carpi ulnaris (FCU)
Extensor carpi ulnaris (ECU)
163
164

Palmaris longus
Flexion
Adduction
Abduction
Joint

Extension
Flowchart 12.1 Muscles producing various movements of the wrist.
N.B.
Flexion is assisted by long flexor tendons of digits (e.g.,
FDS, FDP, and FPL). It occurs more at the midcarpal joint
than at the wrist joint.
Extension is assisted by extensors of the digits (e.g.,
extensor digitorum, extensor digiti minimi, and extensor
indicis). It occurs more at wrist than at midcarpal joint.
Abduction occurs more at midcarpal joint than the wrist
joint.
Adduction mainly occurs at wrist joint.
Flexion and extension of the hand are actually initiated at
the midcarpal joint.
Range of movements (Fig. 12.4)

The range of movements (ROM) of the wrist joint is given in
the box below:
Superficial positions of nerves, vessels, and tendons at
wrist make them exceedingly vulnerable to injury.
Ganglion (Gk = swelling or knot): It is a non-tender cystic
swelling, which sometimes appears on wrist most
commonly on its dorsal aspect. Its size varies from a small
grape to a plum. It usually occurs due to mucoid
degeneration of synovial sheath around the tendon. The
cyst is thin walled and contains clear mucinous fluid. The
flexion of wrist makes the cyst to enlarge and it may
become painful.
Aspiration of the wrist joint: It is usually done by
introducing the needle posteriorly, immediately below the
styloid process of ulna between the tendons of extensor
pollicis longus and extensor indicis.
Immobilization of the wrist joint: The wrist joint is
immobilized in its optimum position of 30 dorsiflexion.
Range of movements of the wrist joint

Movement
Range
Flexion
060
Extension
050
Abduction
015
Adduction
050
JOINTS OF THE HAND

The joints of hand are:
1. Intercarpal joints.
2. Midcarpal joint.
015
050
050
060
Fig. 12.4 Range of movements of the wrist joint.
3. Carpometacarpal joints.
4. Intermetacarpal joints.
Intercarpal joints: These are plane type of synovial joints,
which interconnect the carpal bones. They include the
following joints:
1. Joints between the carpal bones of the proximal row.
2. Joints between the carpal bones of the distal row.
3. Midcarpal joint between the proximal and distal rows of
the carpal bones.
4. Pisotriquetral joint formed between pisiform and
palmar surface of triquetral bone.
Carpometacarpal joints: The carpometacarpal joints are
plane type of synovial joints except for the carpometacarpal
joint of the thumb, which is a saddle joint. The distal
surfaces of the carpals of distal row articulate with the bases
of metacarpals. Functionally and clinically, first
carpometacarpal joint is the most important
carpometacarpal joint and hence described in detail latter.
Intermetacarpal joints: These are plane type of synovial
joints and formed by the articulation of the bases of adjacent
metacarpals of the fingers.
Articular surfaces
Proximal: Distal surface of the trapezium.
Distal: Proximal surface of the base of 1st metacarpal.
Both proximal and distal articular surfaces are reciprocally
concavo-convex; hence permit wide range of movements at
this joint.
Ligaments
1. Capsular ligament (joint capsule): It is thick loose
fibrous sac, which encloses the joint cavity. It is attached
proximally to the margins of articular surface of the
trapezium and distally to the circumference of the base
of first metacarpal bone. The inner surface of the capsule
is lined by the synovial membrane.
2. Lateral ligament: It is a broad fibrous band stretching
from lateral surface of the trapezium to the lateral side
of the base of 1st metacarpal bone.
3. Anterior (palmar) ligament: It extends obliquely from
palmar surface of trapezium to the ulnar side of the base
of 1st metacarpal.
4. Posterior (dorsal) ligament: It also extends obliquely
from dorsal surface of trapezium to the ulnar side of the
base of 1st metacarpal.
N.B. Joint cavities of intercarpal, carpometacarpal, and

intermetacarpal joints: There are the following three joint
cavities among the above-mentioned joints (Fig. 12.1):
Relations
The joints are surrounded by various muscles and tendons
of the thumb. In addition, it is related to:
1. A continuous common cavity of all intercarpal and metacarpal joints, except that of first carpometacarpal joint.
(a) radial artery on its posteromedial sides.

(b) First dorsal interosseous muscle on its medial side.
2. Cavity of first carpometacarpal joint.

3. Cavity of pisotriquetral joint.
Movements of the intercarpal and carpometacarpal joints

are listed in Table 12.2.
Blood supply
By radial artery.
Nerve supply
By median nerve.
First Carpometacarpal Joint (Fig. 12.1)

Type
It is synovial joint of saddle variety.
Movements
The various movements, which take place at the first
carpometacarpal joint are as follows:
Table 12.2 Movements at the intercarpal, carpometacarpal

(except first), metacarpophalangeal, and interphalangeal
joints
1.
2.
3.
4.
5.
Joints
Movements
Intercarpal (IC) joints
Gliding movements
Carpometacarpal (CM) joints

CM joint of thumb
CM joints of second and third
fingers
CM joint of fourth finger
CM joint of fifth finger
Freely mobile
Almost no moment
Flexion and extension.

Abduction and adduction.
Opposition.
Medial and lateral rotation.
Circumduction.
The various movements of thumb at first carpometacarpal

joint are described in detail on pages 168 and 169.
JOINTS OF THE DIGITS (Fig. 12.5)

The joints of digits are:
Slightly mobile
Moderately mobile
1. Metacarpophalangeal joints.
2. Interphalangeal joints.
165
166
DIP joint
Collateral
ligaments
PIP joint
Deep transverse
ligament
Palmar ligament
MP joint
Palmar
ligament
Extensor
tendon
A
B
Fig. 12.5 Joints of the fingers: A, MP joints showing palmar and deep transverse ligaments; B, MP, PIP, and DIP joints
showing palmar and collateral ligaments (DIP = distal interphalangeal, PIP = proximal interphalangeal, MP =
metacarpophalangeal).
Metacarpophalangeal (MP) joints (Fig. 12.5A)

Type: They are synovial joints of ellipsoid/condylar variety.
Articular surfaces: They are formed by heads of metacarpals
and bases of proximal phalanges.
joints of hinge variety. Their structure is similar to that of

MP joints.
Movements
Flexion and extension
Ligaments
1. Palmar ligaments: The palmar ligament is a
fibrocartilaginous plate, which is more firmly attached
to the phalanx than to the metacarpal. The palmar
ligaments of second, third, fourth, and fifth MP joints
are joined to each other by deep transverse metacarpal
ligament.
2. Medial and lateral collateral ligaments: These are cordlike fibrous bands present on each side of the joint and
extend from head of metacarpal to the base of phalanx.
Movements

Flexion and extension

Adduction and abduction
Circumduction
Limited rotation
Interphalangeal (IP) joints (Fig. 12.5B): Both proximal and

distal interphalangeal (PIP and DIP) joints are synovial
MOVEMENTS OF THE HAND

To perform the various movements, the hand adopts a
specific posture. Hence students must first understand the
positions of hand at rest and during function.
POSITION OF THE HAND

Position of the hand at rest (Fig. 12.6)
It is the posture adopted by the hand when it is at rest (i.e.,
not performing any action).
The characteristic features of this position are:
1. Forearm is in semiprone position.
2. Wrist joint is slightly extended.
3. Fingers are partially flexed (index finger is not flexed as
much as the other fingers).
168
FUNCTIONAL COMPONENTS OF THE HAND
MOVEMENTS OF THE THUMB
The hand consists of the following three functional

components (Fig. 12.9):
The metacarpal of the thumb (i.e., first metacarpal) does not

lie in the same plane as the metacarpals of the fingers, but
occupies a more anterior position (Fig. 12.10). In addition, it
is rotated medially through 90, and as a result its extensor
surface is directed laterally and not backwards. For this
reason, the movements of the thumb occur in planes at right
angles to the planes of the corresponding movements of the
fingers. The movements of thumb occur at carpometacarpal,
metacarpophalangeal, and interphalangeal joints. The
movements at the carpometacarpal joint of thumb are much
freer than that of any other finger.
The various movements of thumb are (Fig. 12.11):
1. Central fixed component (central back bone).

2. Radial mobile component.
3. Ulnar mobile component.
The central fixed component is formed by the metacarpals
of index and middle fingers.
The mobile radial component is formed by the thumb.
The mobile ulnar component is formed by the ring and
little fingers.
N.B. The mobile radial component (thumb) comes into play
in precision manipulations against the index finger:
The thumb, index finger, and middle finger together form
the so-called radial digital tripod.
The mobile ulnar component is termed ulnar hook,
which provides for stable power grip with palm or in
hook grip.
The little finger is important for power grip whereas
thumb is important for both power and precision grip.
1.
2.
3.
4.
5.
6.
Flexion.
Extension.
Abduction.
Adduction.
Opposition.
Circumduction.
The movements of thumb, plane of movements, and

muscles producing them are enumerated in the Table 12.3.
N.B. In addition to movements mentioned in Table 12.3,
the following movements of thumb also take place:
Circumduction, a combination of flexion, extension,
abduction, and adduction.
Medial and lateral rotation, which occurs along the long
axis. Medial rotation is produced by opponens and
flexors and lateral rotation by extensors.
Central fixed
component
MOVEMENTS OF THE FINGERS

The movements of fingers occur at metacarpophalangeal
(MP) and proximal interphalangeal and distal interphalangeal
(PIP and DIP) joints. The movements of fingers are:
Radial mobile
component
1. Flexion and extension.

2. Abduction and adduction.
Ulnar mobile
component
Abduction
Flexion
Extension
Adduction
Fig. 12.9 Functional components of the hand.
Fig. 12.10 Position of the metacarpals.
Planes of movements
of thumb
Movement of thumb
Movement of thumb
Thumb
Flexion of
thumb
Extension of
thumb
Palm
In the plane of palm
Abduction
Adduction
Palm
At right angle to the
plane of palm
Adduction of thumb
Abduction of thumb
Palm
Across the plane of palm
Opposition of thumb
Fig. 12.11 Movements of the thumb.
The movements of finger are given in Table 12.4.

Flexion: It is a forward movement of fingers in the
anteroposterior plane and occurs at MP, PIP, and DIP joints.
Extension: It is a backward movement of finger in the
anteroposterior plane and occurs at MP, PIP, and DIP joints.
Abduction: It is a away movement of finger from the
imaginary midline of the middle finger and occurs at MP
joint.
Adduction: It is movement of fingers towards the imaginary

midline of the middle finger and occurs at MP joint.
N.B. The movements of abduction and adduction fingers
are possible only when fingers are in extended position
because in this position the collateral ligaments of MP joints
are slack. In flexed position of fingers the collateral ligaments
of MP joint are taut.
The movements of fingers and muscles producing them

are given in the Table 12.4.
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170
Table 12.3 Movements of the thumb, their plane, and muscles producing them
Movement
Plane of movement
Muscles producing movement
Flexion
Occurs in the plane of palm
Extension
Occurs in the plane of palm
Abduction
Flexor pollicis longus (FPL)

Flexor pollicis brevis (FPB)
Opponens pollicis
Extensor pollicis longus (EPL)
Extensor pollicis brevis (EPB)
Occurs at right angle to the plane of palm

(i.e., anteroposterior plane) away from palm
Adduction
Occurs at right angle to the plane of palm

(i.e., anteroposterior plane) towards the palm
Adductor pollicis
Opposition
Occurs across the palm in such a manner that anterior

surface of the tip of the thumb comes into contact with
anterior surface of the tip of any other finger
Opponens pollicis

Abductor pollicis brevis (APB)
Table 12.4 Movements of the fingers and muscles

producing them
Movement
Flexion
Flexion of proximal
phalanx (MP joint)
Flexion of middle phalanx
(PIP joint)
Flexion of distal phalanx
(DIP joint)
Extension
Extension of proximal
phalanx (MP joint)
Flexion of middle and
distal phalanges (PIP and
DIP joints)
Abduction
Muscles producing them
Lumbricals and interossei

Flexor digitorum
superficialis
Flexor digitorum profundus
Wrist joint moderately flexed
Adduction
MP and IP joints in
neutral position
Extensor digitorum (in

addition by extensor indicis
for index finger and extensor
digiti minimi for little
finger)
Lumbricals and interossei
Dorsal interossei (abductor
digiti minimi abducts the
little finger)
Palmar interossei
MP joints fully flexed
IP joints fully
extended
Fig. 12.12 Position of immobilization (MP = metacarpophalangeal joint, IP = interphalangeal joint).
Fig. 12.13 Position of arthrodesis (MP = metacarpophalangeal joint, IP = interphalangeal joint).
Position of immobilization (Fig. 12.12): The collateral
ligaments of the metacarpophalangeal and interphalangeal
joints extend from the side of the head of proximal bone to
the side of base of the distal bone. The ligaments of MP
joints are on full stretch only when the joint is fully flexed to
90; on the other hand, ligaments of IP joint are stretched/
taut only when the joint is fully extended. This knowledge is
of vital importance when immobilizing the hand because
contracture of the joints occurs within two weeks, if the
joints are immobilized when the ligaments are lax/slack.
Then the shortening of ligaments will cause irreversible
joint contractures. Therefore, the position of immobilization
of hand should be such that the MP joints are fully flexed
and the interphalangeal joints are fully extended.
Position of arthrodesis* (Fig. 12.13): The position of
arthrodesis is one, in which wrist joint is moderately
dorsiflexed (1520), and the MP and IP joint are set in
neutral position.
*Arthrodesis is a surgical procedure consisting of the
obliteration of a joint space by doing bony fusion so that no
movement can occur at the joint.
CHAPTER
13
Major Nerves of the

Upper Limb
The nerve supply to the upper limb is provided by the

brachial plexus (described in detail in Chapter 5, page 70).
The five major nerves supplying the upper limb are:
1.
2.
3.
4.
5.
Axillary nerve.
Musculocutaneous nerve.
Radial nerve.
Median nerve.
Ulnar nerve.
the shoulder. The branches of axillary nerve are shown in

Figure 13.1 (for details see Chapter 5, page 70).
MUSCULOCUTANEOUS NERVE (Fig. 13.2)

The musculocutaneous nerve arises from lateral cord of the
brachial plexus (C5, C6, and C7). It provides motor
innervation to the muscles on the front of the arm and
The study of five major nerves of the upper limb should

be studied thoroughly and carefully because of their frequent
involvement in various injuries and peripheral neuropathy.
C5
Superior
C6
C7
Lateral
Inferior
AXILLARY NERVE (Fig. 13.1)

The axillary nerve (C5 and C6) arises from posterior cord of
brachial plexus. It provides motor innervation to the deltoid
and teres minor muscles and sensory innervation to the
shoulder joint and to the skin over the lower lateral part of
Inferior
AXILLA
Coracobrachialis
Biceps
brachii
C6
Medial
Lateral
MUSCULOCUTANEUS NERVE
C5
Superior
Medial
ARM
Brachialis
Brachialis
Elbow joint
AXILLARY NERVE
Shoulder joint
AXILLA
Posterior branch
Anterior branch
Tendon of biceps brachii
Deep fascia
Teres minor
Pseudoganglion
Skin to lower
half of deltoid
Deltoid
Upper lateral
cutaneous branch of
arm to skin of lower
lateral part of deltoid
Fig. 13.1 Course and distribution of the axillary nerve.
Lateral cutaneous nerve of

forearm to lateral part of
forearm skin
Fig. 13.2 Course and distribution of the musculocutaneous

nerve.
sensory innervation to the skin of the lateral part of the

forearm (for details see Chapter 8, page 96).
RADIAL NERVE (Fig. 13.3)
In the axilla, the radial nerve lies posterior to the third

part of the axillary artery and anterior to the muscles
forming the posterior wall of the axilla.
In the axilla, it gives off the following three branches:
The radial nerve is a continuation of posterior cord of

brachial plexus in the axilla. It is the largest nerve of the
brachial plexus. It carries fibres from all the roots (C5, C6,
C7, C8, and T1) of brachial plexus (but T1 fibres are not
constant).
1. Posterior cutaneous nerve of arm (which provides sensory

innervation to skin on the back of the arm up to the
elbow).
2. Nerve to the long head of triceps.
3. Nerve to the medial head of triceps.
Superior
C5
C6
Lateral
Medial
C7
Inferior
C8
T1
RADIAL NERVE
AXILLA
Posterior cutaneous
nerve of arm

Medial head of triceps
Lateral head of triceps
Lateral intermuscular septum
ARM

nerve of arm
Anconeus
Posterior cutaneous
nerve of forearm
Brachialis (small lateral part)

Brachioradialis
Elbow joint
Deep terminal branch of radial nerve
(posterior interosseous nerve)
Supinator
Extensor carpi
radialis brevis
Extensor digitorum
Superficial terminal branch of radial nerve

(superficial radial nerve)
Radial artery
FOREARM

TENDONS OF

Brachioradialis
Extensor indicis
Inferior radio-ulnar joint
Wrist joint
HAND
Fig. 13.3 Course and distribution of the radial nerve.

Skin of lateral side of dorsum of hand and
lateral 3 digits except nail beds
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174
Radial nerve enters the arm at the lower border of the

teres major. It passes between the long and medial heads of
triceps to enter the lower triangular space, through which it
reaches the spiral groove along with profunda brachii artery.
The radial nerve in the spiral groove lies in direct contact
with the humerus.
N.B. Boundaries of the Spiral Groove
Anteriorly: Middle one-third of the shaft of humerus.
Above:
Origin of the lateral head of triceps.
Below:
Origin of the medial head of triceps.
Posteriorly: Fibres of lateral and long head triceps.
In the spiral groove, it gives off the following five branches:

1. Lower lateral cutaneous nerve of the arm, which provides
sensory innervation to the skin on the lateral surface of
the arm up to the elbow.
2. Posterior cutaneous nerve of the forearm, which provides
sensory innervation to the skin down the middle of the
back of the forearm up to the wrist.
3. Nerve to lateral head of triceps.
4. Nerve to medial head of triceps.
5. Nerve to anconeus (it runs through the substance of
medial head of triceps to reach the anconeus).
At the lower end of the spiral groove, the radial nerve
pierces the lateral muscular septum of the arm and enters the
anterior compartment of the arm. Here, it first descends
between the brachialis and brachioradialis, and then between
brachialis and extensor carpi radialis longus before entering
the cubital fossa.
In the anterior compartment of arm above the lateral
epicondyle, it gives off the following three branches:
1. Nerve to brachialis (small lateral part).
2. Nerve to brachioradialis.
3. Nerve to extensor carpi radialis longus (ECRL).
At the level of lateral epicondyle of humerus, it terminates
by dividing into superficial and deep branches in the lateral
part of the cubital fossa.
The deep branch (also called posterior interosseous
nerve), in the cubital fossa supplies two muscles, viz.
1. Extensor carpi radialis brevis.
2. Supinator.
After supplying these two muscles, it passes through the
substance of supinator and enters the posterior compartment of the forearm and supplies all the extensor muscles of
the forearm. It also gives articular branches to the distal
radio-ulnar, wrist, and carpal joints.
The superficial branch (also called superficial radial
nerve) is sensory. It runs downwards over the supinator,
pronator teres, and flexor digitorum superficialis deep to
brachioradialis. About one-third of the way down the
forearm (at about 7 cm above wrist), it passes posteriorly,
emerging from under the tendon of brachioradialis, proximal

to the styloid process of radius and then passes over the
tendons of anatomical snuff-box, where it terminates as
cutaneous branches which provide sensory innervation to
skin over the lateral part of the dorsum of hand and dorsal
surfaces of lateral 3 digits proximal to the nail beds.
Injuries of the radial nerve: The radial nerve may be
injured at three sites: (a) in the axilla, (b) in the spiral groove,
and (c) at the elbow.
A. Injury of radial nerve in the axilla
In the axilla the radial nerve may be injured by the pressure
of the upper end of crutch (crutch palsy)
Characteristic clinical features in such cases will be as
follows:
Motor loss
Loss of extension of elbowdue to paralysis of triceps.
Loss of extension of wristdue to paralysis of wrist
extensors. This causes wrist drop due to unopposed
action of flexor muscles of the forearm (Fig. 13.4).
Loss of extension of digitsdue to paralysis of extensor
digitorum, extensor indicis, extensor digiti minimi, and
extensor pollicis longus.
Loss of supination in extended elbow because supinator
and brachioradialis are paralyzed but supination becomes
possible in flexed elbow by the action of biceps brachii.
Sensory loss
Sensory loss on small area of skin over the posterior
surface of the lower part of the arm.
Sensory loss along narrow strip on the back of forearm.
Sensory loss on the lateral part of dorsum of hand at the
base of thumb and dorsal surface of lateral 3 digits.
More often, there is an isolated sensory loss on the
dorsum of hand at the base of the thumb (Fig. 13.5).
B. Injury of radial nerve in the radial/spiral groove
In radial groove, the radial nerve may be injured due to:
(a) midshaft fracture of humerus,
(b) inadvertently wrongly placed intramuscular injection,
and
(c) direct pressure on radial nerve by a drunkard falling
asleep with his one arm over the back of the chair
(Saturday night paralysis; Fig. 13.6).
Injury to radial nerve occurs most commonly in the distal
part of the groove beyond the origin of nerve to triceps and
cutaneous nerves.
Clinical features in such cases will be as follows:
Motor loss
Loss of extension of the wrist and fingers.
Wrist drop.
Loss of supination when the arm is extended.
Sensory loss is restricted only to a variable small area

over the dorsum of hand between the first and second
metacarpals.
N.B. Extension of the elbow is possible but may be

little weak because nerves to long and lateral heads of
triceps arises in the axilla i.e., before the site of lesion.
C. Injury of radial nerve at elbow
Radial tunnel syndrome: It is an entrapment neuropathy of
the deep branch of radial nerve at elbow. The compression
of radial nerve at elbow may be caused by the following four
structures:
(a) Fibrous bands, which can tether the radial nerve to the
radio-humeral joint.
(b) Sharp tendinous margin of extensor carpi radialis
brevis.
(c) Leash of vessels from the radial recurrent artery.
(d) Arcade of Frohse, a fibro-aponeurotic proximal edge of
the superficial part of the supinator muscle.
Characteristic clinical features:
Loss of extension of the wrist and fingers but no wrist
drop.
Pain over the extensor aspect of the forearm.
Fig. 13.4 Wrist drop resulting from radial nerve injury.
Isolated
sensory loss
Fig. 13.5 Area of sensory loss in hand following radial nerve

injury above the elbow.
Fig. 13.6 Saturday night paralysis. Note drunk lady falling

asleep with arm over the back of chair.
MEDIAN NERVE (Fig. 13.7)

The median nerve arises from brachial plexus in axilla by
two roots: (a) lateral and (b) medial. The lateral root (C5, C6,
and C7) arises from lateral cord of brachial plexus and
medial root (C8 and T1) arises from medial cord of the
brachial plexus. The medial root crosses in front of the third
part of axillary artery to unite with lateral root in a Y-shaped
manner either in front of or on the lateral side of the artery
to form the median nerve. So the root value of median nerve
is C5, C6, C7, C8, and T1.
In the axilla, the median nerve lies on the lateral side of
the third part of the axillary artery. It enters the arm at the
lower border of teres major.
In the arm, initially, median nerve lies lateral to brachial
artery and then crosses in front of the artery from lateral to
medial side at the level of midhumerus (i.e., level of insertion
of coracobrachialis). After crossing, it runs downwards to
enter cubital fossa.
In the cubital fossa, the median nerve lies medial to the
brachial artery and tendon of biceps brachii. Here it is
covered by bicipital aponeurosis, which separates it from the
median cubital vein.
In the cubital fossa, it gives muscular branches from its
medial side to supply all the superficial flexors of the forearm
flexor carpi radialis, palmaris longus, and flexor digitorum
superficialis) except flexor carpi ulnaris.
Median nerve leaves the cubital fossa by passing between
the two heads of pronator teres. At this point, it gives off
anterior interosseous nerve.
The anterior interosseous nerve is purely motor and
supplies 2 muscles:
1. Flexor pollicis longus.
2. Lateral half of the flexor digitorum profundus (FDP).
3. Pronator quadratus.
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176
Superior
C5
C6
Lateral
C7
C8
Medial
Inferior
T1
MEDIAN NERVE
AXILLA
Brachial artery
ARM
Biceps tendon
Pronator teres

Palmaris longus
Flexor pollicis longus

FOREARM
Flexor digitorum superficialis
Flexor digitorum
profundus (lateral half)
Pronator quadratus
Flexor digitorum superficialis
Wrist and inferior

radio-ulnar joint
(lateral of palmar skin)
Flexor retinaculum

HAND

Opponens pollicis
RB
1st lumbrical
2nd lumbrical
Palmar digital branches
(lateral 3 digits including
nail beds)
Fig. 13.7 Course and distribution of the median nerve (RB = recurrent branch).
In the forearm, the median nerve passes downwards behind

the tendinous arch/bridge between the two heads of flexor
digitorum superficialis and runs deep to the flexor digitorum
superficialis. About 5 cm proximal to the flexor retinaculum,
the median nerve emerges from the lateral side of the FDS and
becomes superficial, lying lateral to the tendons of FDS and
posterior to the tendon of palmaris longus.
In the midarm, the median nerve gives muscular branch
to the radial head of flexor digitorum superficialis, which
gives rise to tendon for index finger.
Before entering the carpal tunnel, it gives off its palmar
cutaneous branch, which passes superficial to the flexor
retinaculum to supply the skin over the thenar eminence and
lateral part of the palm.
Median nerve enters the palm by passing through carpal
tunnel where it lies deep to flexor retinaculum and superficial
to the tendons of FDS, FDP, and FPL and their associated
ulnar and radial bursae.
In the palm, the median nerve flattens at the distal border
of the flexor retinaculum and divides into lateral and medial
divisions. The lateral division gives a recurrent branch,
which curls upwards to supply thenar muscles except the
deep head of flexor pollicis brevis. It then divides into three
palmar digital branches. The medial divisions give off two
palmar digital nerves.
The five palmar digital nerves supply:
(a) sensory innervation to the skin of the palmar aspect of
the lateral 3 digits including nail beds and skin on the
dorsal aspect of distal phalanges, and
(b) first and second lumbricals.
N.B.
Median nerve is also termed laborers nerve because the
coarse movements of the hand required by laborers (e.g.,
digging the ground, lifting weight, etc.) are performed by
long flexors of the forearm which are mostly supplied by
the median nerve.
It is also termed eye of the hand or peripheral eye
because it provides sensory innervation to the pulp of the
thumb and index finger which are used to see the
thinness and texture of cloth and are also used for
performing fine movements, e.g., buttoning a coat.
Injuries of the median nerve: The lesions of median nerve
may occur at the following four sites: (a) at elbow, (b) at
mid-forearm, (c) at wrist (distal forearm), and (d) in the
carpal tunnel.
A. Injury of the median nerve at the elbow: At elbow the
median nerve can be injured due to:
(a) supracondylar fracture of humerus,
(b) application of tight tourniquet during venipuncture, and
(c) entrapment of nerve between two heads of pronator

teres or under the fibrous arch connecting the two
heads of flexor digitorum superficialis.
follows:
Forearm kept in supine position (loss of pronation), due to
paralysis of pronator teres.
Wrist flexion is weakdue to paralysis of all the flexors of
forearm except medial half of FDP and flexor carpi ulnaris.
Adduction of wristdue to paralysis of FCR and
unopposed action of FCU and medial half of FDP.
No flexion is possible at the interphalangeal (IP) joints of
index and middle fingers.
Benediction deformity of the hand (Fig. 13.8A), i.e., when
patient tries to make fist, the index and middle fingers remain
straight, due to paralysis of both superficial and deep flexors
of these fingers leading to loss of flexion at PIP and DIP
joints. The ring and the little finger can be kept in flexed
position due to intact nerve supply of medial half of the FDP.
Loss of flexion of terminal phalanx of thumb, due to
paralysis of FPL.
Ape-thumb deformity (Fig. 13.8B), in which thenar
eminence is flattened and thumb is laterally rotated and
adducted, due to paralysis of muscles of thenar eminence
and normal adductor pollicis, respectively.
Loss of sensation in lateral half of the palm and lateral 3
digits and also on the dorsal aspects of same digits
(Fig. 13.9).
B. Injury of the median nerve at the mid-forearm: The injury
of median nerve at mid-forearm results in pointing index finger
due to paralysis of radial head of FDS muscle that continues as
tendon of index finger; other signs and symptoms will be same
as those which occur in lesion at distal forearm and wrist.
C. Injury of the median nerve at wrist (distal forearm): At
wrist, median nerve and its palmar cutaneous branch may
be injured just proximal to the flexor retinaculum by deep
lacerated wounds (cut injury), e.g., suicidal cuts.
Characteristic clinical features in such a case will be as follows:
Ape-thumb deformity, due to paralysis of muscles of
thenar eminence.
Loss of sensation on the lateral part of the palm (including
that over the thenar eminence) and lateral 3 digits
including loss of sensation on the dorsal aspect of these
digits (Fig. 13.9).
D. Injury in the carpal tunnel: The median nerve is injured in
the carpal tunnel due to its compression and produces a
clinical condition called carpal tunnel syndrome. The carpal
tunnel is formed by anterior concavity of carpus and flexor
retinaculum. The tunnel is tightly packed with nine long flexor
tendons of fingers and thumb with their surrounding synovial
sheaths and median nerve. The median nerve gets
compressed in the tunnel due to its narrowing following a
number of pathological conditions such as
(a) tenosynovitis of flexor tendons (idiopathic),
(b) myxedema (deficiency of thyroxine),
(c) retention of fluid in pregnancy,
(d) fracture dislocation of lunate bone, and
(e) osteoarthritis of the wrist.
177
178
Characteristic clinical features of the carpal tunnel

syndrome are as follows:
Feeling of burning pain or pins and needles along the
sensory distribution of median nerve (i.e., lateral 3
digits) especially at night.
There is no sensory loss over the thenar eminence
because skin over thenar eminence is supplied by the
palmar cutaneous branch of the median nerve, which
passes superficial to flexor retinaculum.
Weakness of thenar muscles.
Ape-thumb deformity may occur, if left untreated, due to
paralysis of the thenar muscles.
Positive Tinels sign (Fig 13.10) and Phalens test
(Fig. 13.11).
Reduced conduction velocity in the median nerve (<30
m/s) is diagnosis.
Flexor retinaculum
N.B. The signs and symptoms of the carpal tunnel

syndrome are dramatically relieved by decompressing
the tunnel by giving a longitudinal incision through flexor
retinaculum.
Fig. 13.10 Tinels sign. Percussion over flexor retinaculum
reproduces patients symptoms.
Benediction
attitude
Median nerve
Thumb
rotated
laterally
Fig. 13.8 Effects of the median nerve injury: A, benediction

deformity of the hand (benediction attitude of hand);
B, ape-thumb deformity.
Fig. 13.11 Phalens test. Flexion of both wrists against each

other for one minute reproduces patients symptoms.
ULNAR NERVE (Fig. 13.12)
Fig. 13.9 Area of sensory loss in hand following injury of

the median nerve.
The ulnar nerve arises in the axilla from the medial cord of
brachial plexus (C8 and T1). It receives a contribution from
the ventral ramus of C7. The C7 fibres in the ulnar nerve
supply flexor carpi ulnaris.
In the axilla, the nerve lies medial to third part of axillary
artery (between axillary artery and vein).
It enters the arm as part of main neurovascular bundle
and runs distally along the medial side of the brachial
Superior
C8
Medial
Lateral
T1
Inferior
ULNAR NERVE
AXILLA
Brachial artery
Medial intermuscular septum of arm
ARM
Elbow joint
Ulnar artery
Flexor digitorum profundus (medial half)
FOREARM

(medial of palmar skin)
Dorsal cutaneous branch

(skin of medial side of dorsum
of hand and medial 1 fingers)
Palmaris brevis
HAND
Deep terminal branch

Palmar aspect of
medial 1 digits
Wrist joint
Superficial
terminal branch
Adductor pollicis
Flexor pollicis
brevis (often)
3 palmar interossei
2 medial lumbricals
4 dorsal interossei
Fig. 13.12 Course and distribution of the ulnar nerve.
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180
artery up to the midarm (level of insertion of

coracobrachialis) where it pierces the medial intermuscular
septum to enter the posterior compartment of the arm and
runs downwards to the back of the medial epicondyle of
humerus. On the back of medial epicondyle, it is lodged in
a groove where it can be easily palpated. The groove is
converted into a tunnel called cubital tunnel by a fibrous
band extending between medial epicondyle and olecranon
process. The ulnar nerve crosses the ulnar collateral
ligament in the floor of the tunnel.
The ulnar nerve does not give any branch in the axilla and
in the arm.
The nerve enters the forearm by passing between the two
heads of flexor carpi ulnaris. In the upper third of forearm, it
runs almost vertically downwards under flexor carpi ulnaris.
In the lower two-third of the forearm, it becomes superficial
and lies lateral to the flexor carpi ulnaris. In this part of its
course the ulnar nerve and artery descend together, artery
being on the lateral side of the nerve.
In the forearm, it gives off the following branches:
1. In the proximal forearm, it gives muscular branches to:
(a) flexor carpi ulnaris, and
(b) medial half of flexor digitorum profundus.
2. In the mid-forearm, it gives off palmar cutaneous branch,
which enters the palm superficial to the flexor
retinaculum to provide sensory innervation to the skin
over the hypothenar eminence.
3. In the distal forearm, about 5 cm proximal to the wrist,
it gives off dorsal cutaneous branch which provides
sensory innervation to the skin over the medial third of
the dorsum of the hand and medial 1 finger.
The ulnar nerve enters the palm by passing superficial to
the flexor retinaculum lying just lateral to the pisiform. Here
the ulnar nerve is covered by a fascial band (volar carpal
ligament). The space under this fascial band is termed ulnar
tunnel. Just distal to pisiform, the ulnar nerve divides into its
terminal superficial and deep branches. The superficial
terminal branch supplies palmaris brevis provides sensory
innervation to the skin on the palmar surface of medial 1
fingers.
The deep terminal branch enters Guyons canal (pisohamate
tunnel) under cover of pisohamate ligament and turns
laterally within concavity of deep palmar arterial arch and
ends within substance of adductor pollicis which it supplies.
The deep branch of ulnar nerve is purely motor and supplies all
the intrinsic muscles of the hand except the muscles of thenar
eminence and first two lumbricals.
N.B. The ulnar nerve is often referred to as nerve of fine
movements/musicians nerve because it innervates most
of the intrinsic muscles of the hand that are involved in the
fine intricate hand movements as required by the musicians

while playing musical instruments.
The ulnar nerve behind medial epicondyle of humerus is
termed funny bone because when the medial part of the
elbow hits a hard surface, tingling sensations occur along
the ulnar side of the forearm and hand.
Injuries of the ulnar nerve: The ulnar nerve is commonly
injured at two sites: (a) at elbow and (b) at wrist.
A. Injury of the ulnar nerve at elbow: The injury of ulnar
nerve at elbow may occur due to:
(a) fracture dislocation of the medial epicondyle,
(b) thickening of the fibrous roof of the cubital tunnel
(cubital tunnel syndrome), and
(c) compression between the two heads of flexor carpi
ulnaris (FCU) muscle, and
(d) valgus deformity of elbow (tardy or late ulnar nerve
palsy).
follows (Fig. 13.13):
Atrophy and flattening of hypothenar eminence.
Claw-hand deformity (main en griffe) affecting ring and
little fingers. The first phalanges of these fingers are
extended and middle and distal phalanges are flexed
(Fig. 13.3A).
It is not a true claw hand.
Loss of abduction and adduction of fingers.
Flattening of hypothenar eminence and depression of
interosseous spaces on dorsum of hand due to atrophy of
interosseous muscles, respectively (Fig. 13.3B).
Loss of adduction of thumb.
Loss of sensation over the palmar and dorsal surfaces of
the medial third of the hand and medial 1 fingers
(Fig. 13.14).
Foments sign is positive (Fig. 13.15).*
B. Injury of the ulnar nerve at wrist: The ulnar nerve at
wrist is injured due to
(a) superficial position of ulnar nerve at this site makes its
vulnerable to cuts and wounds, and
(b) compression in the Guyons canal/pisohamate tunnel.
follows:
Claw-hand deformity affecting ring and little fingers (ulnar
claw hand) but it is more pronounced (ulnar paradox)
because the FDP is not paralyzed; therefore there is a
marked flexion of DIP joints.
Atrophy and flattening of hypothenar eminence.
Loss of abduction and adduction of fingers.
Foments sign is positive.
N.B. Complete claw hand (Fig. 13.16): The combined

lesions of the median and ulnar nerves at elbow
cause a true/complete claw-hand deformity. The
characteristic clinical features of a true claw hand are
as follows:
Hyperextension of the wrist and metacarpophalangeal
(MP) joints.
Flexion of interphalangeal (IP) joints.
*Foments sign: The patient is asked to grasp the card
between the thumb and index finger on the affected side
and when the examining doctors pulls it, the flexion of distal
phalanx of thumb occurs due to paralysis of adductor pollicis
(i.e., Foments sign is positive).
Fig. 13.14 Sensory loss in the hand following ulnar nerve

injury: A, Palmar aspect; B, dorsal aspect.
The features of the three principal nerves (radial,

median, and ulnar) of upper limb are summarized in
Table 13.1.
AUTONOMOUS SENSORY AREAS OF THE HAND
Fig. 13.13 Effects of the ulnar nerve injury: A, ulnar claw

hand; B, hollowing of skin in the first web space on dorsal
aspect of hand.
An autonomous sensory area is that part of the dermatome

that has no overlap from the adjacent nerves.
The autonomous sensory areas of the hand are used to
test the integrity of nerves supplying the hand (e.g., ulnar,
median, and radial). The autonomous sensory areas of the
radial, median, and ulnar nerves are shown in Figure
13.17.
Fig. 13.15 Foments sign to test the integrity of palmar interossei. The wrist should be dorsiflexed to rule out the action of
long flexors of fingers.
181
182
Median nerve
Ulnar nerve
Radial nerve
Fig. 13.16 Complete claw hand following combined lesions

of the median and ulnar nerves.
Fig. 13.17 Autonomous sensory areas of the radial, median,

and ulnar nerves.
Table 13.1 Characteristics of radial, median, and ulnar nerves of the upper limb
Nerve
Radial nerve
Median nerve
(syn. Laborers nerve)
Ulnar nerve
(syn. Musicians nerve)
Origin
Posterior cord of brachial

plexus
Medial and lateral cords of brachial

plexus
Medial cord of brachial plexus
Root value
C5T1
C5T1
C8T1
Motor innervation
Supplies all the muscles on

Supplies
Supplies
the back of arm and forearm all the muscles on the front of
One-and-half muscles of the forearm
forearm except flexor carpi ulnaris
(flexor carpi ulnaris and medial half of
and medial half of flexor digitorum
the flexor digitorum profundus)
profundus
all the intrinsic muscles of the hand,
muscle of thenar eminence and first
except first two lumbricals and
two lumbricals
muscles of thenar eminence
Sensory innervation Posterior surface of the

arm and forearm
Dorsal aspect of lateral
2/3rd of hand and lateral
3 digits
Effects of lesion
Wrist drop
Palmar aspect of lateral 2/3rd of hand, Palmar aspect of medial 1/3rd of hand
and lateral 3 digits including their
and medial 1 fingers
dorsal tips
Ape-thumb deformity (Simians
Absence of extension of
MP joints of digits
Loss of sensation to a
variable small area over
the root of the thumb
hand)
Wasting of thenar eminence
Absence of abduction of thumb
Pointing index finger
Absence of opposition of thumb
Loss of sensation on the palmar
aspect of lateral part of hand and
lateral 3 digits
Claw-hand deformity (main en griffe)

Wasting of hypothenar eminence
Absence of abduction and adduction
of fingers
Loss of sensation on the ulnar side of
the hand and medial 1 digits
Table 13.2 Segmental innervation of the muscles of the upper limb

Segment
Muscles innervated
C5
Deltoid
Supraspinatus, infraspinatus, and teres minor
Rhomboideus major and minor
Coracobrachialis, biceps brachii, and brachialis
Brachioradialis and supinator
(Abductors and lateral rotators of the shoulder; flexors and supinators of the forearm)
C6
Pectoralis major and minor

Subscapularis, latissimus dorsi, and teres major
Serratus anterior
Triceps
Pronator teres and pronator quadratus
(Adductors and medial rotators of the shoulder; extensors and pronators of the forearm)
C7
Extensors and flexors of the wrist
C8
Long flexors and extensors of the fingers
T1
Small muscles of the hand
SEGMENTAL INNERVATION OF THE

MUSCLES OF THE UPPER LIMB
The knowledge of these segmental values is of importance
in the diagnosis of injuries to the nerves or to the
spinal cord from which they arise. The segmental

innervation of the muscles of the upper limb is given in
Table 13.2. These are based on the clinical data observed
by Kocher.
183
CHAPTER
14
Introduction to Thorax
and Thoracic Cage
The thorax is the upper part of trunk, which extends from

root of the neck to the abdomen. In general usage, the term
chest is used as a synonym for thorax. The cavity of trunk is
divided by the diaphragm into an upper part called thoracic
cavity and the lower part called the abdominal cavity. The
thoracic cavity contains the principal organs of respiration
the lungs, which are separated from each other by bulky and
movable median septum the mediastinum. The principal
structures in the mediastinum are heart and great vessels.
T1
Manubrium
Costal
cartilages
THORACIC CAGE
The thorax is supported by a skeletal framework called
thoracic cage. It provides attachment to muscles of thorax,
upper extremities, back, and diaphragm. It is
osteocartilaginous and elastic in nature. It is primarily
designed for increasing or decreasing the intrathoracic
pressure so that air is sucked into lungs during inspiration
and expelled from lungs during expirationan essential
mechanism of respiration.
FORMATION OF THORACIC CAGE (Fig. 14.1)

The thoracic cage is formed:
Anteriorly: by sternum (breast bone).
Posteriorly: by 12 thoracic vertebrae and intervening
intervertebral discs.
Laterally:
by 12 pairs of ribs and associated 12 pairs of
each side:
costal cartilages.
The rib cage is formed by sternum, costal cartilages, and
ribs attached to the thoracic vertebrae.
The ribs articulate as follows:
1. Posteriorlyall the ribs articulate with the thoracic
vertebrae.
2. Anteriorly(a) the upper seven ribs (1st7th)
articulate with the side of sternum
through their costal cartilages.
1st rib
Body
Xiphoid
process
T11
T12
12th rib
Fig. 14.1 Anterior aspect of thoracic cage.
(b) The next three ribs (e.g., 8th, 9th, and

10th) articulate with each other
through their costal cartilages.
(c) The lower two ribs (e.g., 11th and
12th) do not articulate and anterior
ends of their costal cartilages are free.
N.B. The costal cartilages of 7th, 8th, 9th, and 10th ribs
form a sloping costal margin.
SHAPE OF THORACIC CAGE (Fig. 14.2)

The thoracic cage resembles a truncated cone with its narrow
end above and broad end below. The narrow upper end is
continuous above with root of neck from which it is partly
186
Neck
Sibsons fascia
Shoulder
Thoracic
cavity
Abdominal
cavity
Diaphragm
Fig. 14.2 Thoracic cage and thoracic cavity: A, shape of thoracic cage; B, schematic diagram to show how the size of thoracic
cavity is reduced by upward projection of the diaphragm and by inward projection of the shoulder.
separated on either side by the suprapleural membranes. The

broad lower end is completely separated from abdominal
cavity by the diaphragm, but provides passage to structures
like, aorta, esophagus, and inferior vena cava.
The diaphragm is dome shaped with its convexity directed
upwards. Thus, the upper abdominal viscera lies within the
thoracic cage and are protected by it.
In life, the upper end of thorax appears broad due to the
presence of shoulder girdle made up of clavicles and scapulae
and associated scapular musculature.
N.B. The thoracic cavity is actually much smaller than one

assumes because the upper narrow part of thoracic cage
appears broad (vide supra) and lower broad part of thoracic
cage is encroached by the abdominal viscera due to domeshaped diaphragm.
TRANSVERSE SECTION OF THORAX

In transverse section, the adult thorax is kidney shaped with
transverse diameter more than the anteroposterior diameter
(Fig. 14.3B, C). This is because the ribs are placed obliquely
in adults.
In transverse section, the thorax of infants below the age
of two years is circular with equal transverse and
anteroposterior diameter (Fig. 14.3A). This is because the
ribs are horizontally placed.
The transverse sections of thorax in adult and infant are
compared in Table 14.1.
Fig. 14.3 The shape of thoracic cavity as seen in transverse

section of thorax: A, in infant; B, in adult; C, transverse
section of adult thorax in CT scan.
Table 14.1 Comparison of thoracic cavity as seen in

transverse sections of the thorax in adult and infant
Thoracic cavity in adult
Thoracic cavity in infant
Kidney shaped
Circular
Ribs obliquely placed
Ribs horizontally placed
Transverse diameter can be

increased by thoracic
breathing (Hence respiration
is thoraco-abdominal)
Transverse diameter cannot be

increased by thoracic
breathing (Hence respiration
is purely abdominal)
The thorax up to 2 years after birth is circular in cross
section. Therefore, the diameter of thorax cannot be
increased within the circumference, the length of which
remains constant. Therefore, in children up to the 2 years of
age, the respiration is almost entirely abdominal.
Consequently, young children are prone to suffer from
pneumonia after abdominal operations, because they
resist breathing (being abdominal) due to pain. As a result
the secretions in the lungs tend to accumulate, which may
become infected and cause pneumonia.
Anterior border of
superior surface of
T1 vertebra
Medial border
of first rib
Thoracic inlet
Medial border
of first costal
cartilage
Upper border of
manubrium sterni
Fig. 14.4 Boundaries of the thoracic inlet.
1
2
First rib
3
Manubrium
4
6
7
SUPERIOR THORACIC APERTURE

(THORACIC INLET)
The thoracic cavity communicates with the root of the neck
through a narrow opening called superior thoracic aperture
or thoracic inlet.
N.B. The superior thoracic aperture is called thoracic outlet
by the clinicians because important arteries and T1 spinal
nerves emerge from thorax through this aperture and enter
the neck and upper limbs.
Anatomists refer to the superior thoracic aperture as
thoracic inlet because air and food enter the thorax through
trachea and esophagus, respectively.

Anteriorly:
Superior border of manubrium sterni.
Posteriorly:
Anterior border of the superior surface of the

body of T1 vertebra.
Laterally
(on each
side):
Medial border of first rib and its cartilage.
The upper end of anterior boundary lies 1.5 inches below

the upper end of posterior boundary because first rib slopes
downwards and forwards from its posterior end to anterior
8
Xiphoid
process
9
10
Diaphragm
11
12
Fig. 14.5 Superior thoracic aperture; arrow (lateral view).
end (Fig. 14.5). Therefore, plane of thoracic inlet slopes

(directed) downwards and forwards with an obliquity of
about 45. The upper border of manubrium sterni lies at the
level of upper border of T3 vertebra (Fig. 14.6).
N.B. Due to downward and forward inclination of thoracic
inlet, the apex of lung with the overlying pleura projects into
the root of the lung.
Shape and Dimensions

Shape: Reniform/kidney shaped.
Dimensions: Transverse diameter: 4.5 inches.
Anteroposterior diameter: 2.5 inches.
187
188
Upper end of
posterior boundary
Plane of
thoracic inlet
Intervertebral
discs
T1
45
T2
1.5"
T3
Upper end
of anterior
boundary
Functions
The functions of Sibsons fascia are as follows:
1. It protects the underlying cervical pleura, beneath which
lies the apex of the lung.
2. It resists the intrathoracic pressure during respiration.
As a result, the root of neck is not puffed up and down
during respiration.
N.B. Morphologically, Sibsons fascia represents the spread
out degenerated tendon of scalenus minimus (or pleuralis)
muscle.
T4
Manubrium
sterni
Structures Passing Through Thoracic Inlet (Fig. 14.8)

Muscles
1. Sternohyoid.
2. Sternothyroid.
3. Longus cervicis/longus colli.
Arteries
1. Right and left internal thoracic arteries.
2. Brachiocephalic trunk/artery.
3. Left common carotid artery.
4. Left subclavian artery.
5. Right and left superior intercostal arteries.
Nerves
1. Right and left vagus nerves.
2. Left recurrent laryngeal nerve.
3. Right and left phrenic nerves.
4. Right and left first thoracic nerves.
5. Right and left sympathetic chains.
Veins
1. Right and left brachiocephalic veins.
2. Right and left 1st posterior intercostal veins.
3. Inferior thyroid veins.
Fig. 14.6 Plane of the thoracic inlet.
DIAPHRAGM OF SUPERIOR THORACIC APERTURE

(SUPRAPLEURAL MEMBRANE/SIBSONS FASCIA)
The part of thoracic inlet, on either side, is closed by a
dense fascial sheet called suprapleural membrane or
Sibsons fascia, or diaphragm of superior thoracic
aperture. It is tent-shaped.
Attachments and Relations (Fig. 14.7)

The apex of Sibsons fascia is attached to the tip of transverse
process of C7 vertebra, and its base is attached to the inner
border of first rib and its costal cartilage. Its superior
surface is related to the subclavian vessels and its inferior
surface is related to cervical pleura, covering the apex of the
lung.
Transverse process
of C7 vertebra
C7
C7
T1
T1
Transverse process of
C7 vertebra
Sibsons fascia
(suprapleural membrane)
Subclavian artery
Cervical pleura
First rib
Sibsons fascia
(suprapleural
membrane)
Apex of lung
First rib
First costal
cartilage
A
Subclavian vein
Fig. 14.7 Suprapleural membrane/Sibsons fascia: A, attachments; B, relations.
Esophagus
Longus cervicis (colli)
Trachea
First thoracic nerve
Superior intercostal artery
First posterior intercostal vein
Apex of lung
Sympathetic chain
Thoracic duct
Left recurrent laryngeal nerve
Left subclavian artery
Right phrenic nerve
Left phrenic nerve
Left vagus nerve
Right brachiocephalic vein
Left common carotid artery

Left brachiocephalic vein
Right internal thoracic artery
Left internal thoracic artery

Sternothyroid
Brachiocephalic artery
Sternohyoid
Inferior thyroid vein
Thymus
Fig. 14.8 Structures passing through the thoracic inlet.
Lymphatics
Thoracic duct.
Others
1. Anterior longitudinal ligament.
2. Esophagus.
3. Trachea.
4. Right and left domes of cervical pleura.
5. Apices of right and left lungs.
Thoracic inlet syndrome: The subclavian artery and
lower trunk of the brachial plexus arch over the first rib,
hence they may be stretched and pushed up by the
presence of a congenitally hypertrophied scalenus anterior
muscle or a cervical rib. This leads to thoracic inlet
syndrome (also called scalenus anterior syndrome or
cervical rib syndrome). It presents the following clinical
features:
Numbness, tingling, and pain along the medial side of
forearm and hand, and wasting of small muscles of the
hand due to the involvement of lower trunk of brachial
plexus (T1).
There may be ischemic symptoms in the upper limb
such as pallor and coldness of the upper limb, and
weak radial pulse due to compression of the subclavian
artery.
INFERIOR THORACIC APERTURE

(THORACIC OUTLET)
The inferior thoracic aperture is broad and surrounds
the upper part of the abdominal cavity. The large
musculoaponeurotic diaphragm attached to the margins of
thoracic outlet separates the thoracic cavity from the
abdominal cavity.
Boundaries
Anteriorly:
Xiphisternal joint.
Posteriorly:
Body of 12th thoracic vertebra.
Laterally
(on each
side):
Costal margin and 11th and 12th ribs.
DIAPHRAGM OF INFERIOR THORACIC APERTURE

(Fig. 14.9)
The thoracic outlet is closed by a large dome-shaped flat
muscle called diaphragm. Since it separates thoracic cavity
from abdominal cavity, it is also termed thoraco-abdominal
diaphragm.
The diaphragm is the principal muscle of respiration. It is
dome shaped and consists of peripheral muscular part, and
central fibrous part called central tendon.
189
190
Median arcuate
ligament
12th rib
T12
7th rib
Xiphisternum
Superior
epigastric vessels
Inferior vena cava
L1
Musculophrenic
artery
L2
Right crus of
diaphragm
Intercostal
nerve and
vessels
L3
Lateral arcuate
ligament
Medial arcuate
ligament
Left crus of
diaphragm
Left vagal trunk
Right phrenic
nerve
Esophagus
Central
tendon
Esophageal branch of
left gastric artery
Right vagal trunk
Median arcuate ligament
Lateral arcuate ligament
12th rib
Subcostal nerve and vessels
Azygos vein
Thoracic duct
Medial arcuate ligament

Left crus of diaphragm
Aorta
Right crus of diaphragm
Sympathetic chain
Fig. 14.9 Origin, insertion, and openings of the diaphragm. Figure in the inset shows details of vertebral origin of the
diaphragm.
Origin
The origin of the diaphragm is divided into three parts, viz.
1. Sternal.
2. Costal.
3. Vertebral.
Sternal part: It consists of two fleshy slips, which arise from
the posterior surface of the xiphoid process.
Arcuate ligaments

Costal part: On each side, it consists of six fleshy slips, which

arise from the inner surface of lower six ribs near their costal
cartilages.
Vertebral part: This part arises by means of (a) right and left
crura of diaphragm and (b) five arcuate ligaments.
Crura
Right crus: It is a vertical fleshy bundle, which arises from

the right side of anterior aspects of the upper three lumbar
vertebrae and intervening intervertebral discs.
Left crus: It is vertical fleshy bundle, which arises from the

left side of anterior aspects of upper two lumbar vertebrae
and the intervening intervertebral discs.
The medial margins of the crura are tendinous.
Median arcuate ligament is an arched fibrous band

stretching between the upper ends of two crura.
Medial arcuate ligament is the thickened upper margin of
the psoas sheath. It extends from the side of the body of
L2 vertebra to the tip of the transverse process of L1
vertebra.
Lateral arcuate ligament is the thickened upper margin of
fascia covering the anterior surface of the quadratus
lumborum. It extends from the tip of transverse process
of L1 vertebra to the 12th rib.
N.B. The right crus is attached to more number of vertebrae

because the right side diaphragm has to contract on the
massive liver.
Insertion
From circumferential origin (vide supra), the muscle fibres
converge towards the central tendon and insert into its
margins.
The features of the central tendon are as follows:
1. It is trifoliate in shape, having (a) an anterior (central)
leaflet, and (b and c) two tongue-shaped posterior
leaflets. It resembles an equilateral triangle. The right
posterior leaflet is short and stout, whereas the left
posterior leaflet is thin and long.
2. It is inseparably fused with the fibrous pericardium.
3. It is located nearer to the sternum than to the vertebral
column.
Surfaces and Relations
The superior surface of diaphragm projects on either side
as dome or cupola into the thoracic cavity. Depressed area
between the two domes is called central tendon. The
superior surface is covered by endothoracic fascia and is
related to the bases of right and left pleura on the sides and
to the fibrous pericardium in the middle.
The inferior surface of diaphragm is lined by the
diaphragmatic fascia and parietal peritoneum.
On the right side it is related to (a) right lobe of the liver,
(b) right kidney, and (c) right suprarenal gland.
On the left side it is related to (a) left lobe of the liver,
(b) fundus of stomach, (c) spleen, (d) left kidney, and
(e) left suprarenal gland.
Table 14.2 Location, shape, and vertebral level of three

major openings of the diaphragm
Opening
Location
Vertebral
level
Vena caval In the central tendon Quadrangular T8 (body)

opening
slightly to the right of or square
median plane
between the central
and right posterior
leaflets
Esophageal Slightly to the left of
opening
median plane (The
fibres of right crus
split around the
opening and act like
pinch cock)
Aortic
opening
Oval or
elliptical
In the midline behind Circular or

the median arcuate
round
ligament
T10 (body)
T12 (lower
border of
the body)
Table 14.3 Structures passing through three major

openings of the diaphragm
Opening
Structures passing through
Vena caval
opening
Inferior vena cava
Esophageal
opening
Esophagus
Openings of the Diaphragm

The openings of diaphragm are classified into two types:
(a) major openings and (b) minor openings.
Shape
Right phrenic nerve
Right and left vagal trunks

Esophageal branches of left gastric artery
Aortic opening
From right to left these are:

Azygos vein
Thoracic duct
Major Openings
Aorta
There are three named major openings, viz.

1. Vena caval opening.
2. Esophageal opening.
3. Aortic opening.
Contraction of diaphragm has no effect on the aortic

opening because strictly it is outside the diaphragm.
The location, shape, and vertebral levels of these openings

are presented in Table 14.2.
The structure passing through three major opening of
diaphragm are listed in Table 14.3.
Minor Openings
N.B.
Contraction of diaphragm enlarges the caval opening to
enhance venous return.
Contraction of diaphragm has a sphincteric effect on the
esophageal opening (pinch-cock effect).
1. Superior epigastric vessels pass through the gap (space

of Larry) between the muscular slips arising from
xiphoid process and 7th costal cartilage.
2. Musculophrenic artery passes through the gap between
the slips of origin from 7th to 8th ribs.
These are unnamed. Structures passing through these

openings are as follows:
191
192
3. Lower five intercostal nerves and vessels (i.e., 7th11th)

pass through gaps between the adjoining costal slips.
4. Subcostal nerves and vessels pass deep to the lateral
arcuate ligament.
5. Sympathetic chain passes deep to the medial arcuate
ligament.
6. Greater, lesser, and least splanchnic nerves pass by
piercing the crus of diaphragm on the corresponding
side.
7. Hemiazygos vein pierces the left crus of the diaphragm.
Nerve Supply
The diaphragm is supplied by:
(a) right and left phrenic nerves, and
(b) lower five intercostal and subcostal nerves.
The phrenic nerves are both motor and sensory. The right
phrenic nerve provides motor innervation to the right half of
the diaphragm up to the right margin of esophageal opening,
and left phrenic nerve provides motor innervation to the left
half of the diaphragm up to the left margin of the esophageal
opening.
The phrenic nerves provide sensory innervation to the
central tendon of the diaphragm, and pleura and peritoneum
related to it.
The intercostal nerves supply the peripheral parts of the
diaphragm.
Arterial Supply
The diaphragm is supplied by the following arteries:
1. Superior phrenic arteries (also called phrenic arteries)
from thoracic aorta.
2. Inferior phrenic arteries, from the abdominal aorta.
3. Pericardiophrenic arteries, from the internal thoracic
arteries.
4. Musculophrenic arteries, the terminal branches of the
internal thoracic arteries.
5. Superior epigastric arteries, the terminal branches of
the internal thoracic arteries.
6. Lower five intercostal and subcostal arteries from the
aorta.
Lymphatic Drainage
The lymph from diaphragm is drained into the following
groups of lymph nodes:
1. Anterior diaphragmatic lymph nodes, situated behind
the xiphoid process.
2. Posterior diaphragmatic lymph nodes, situated near the
aortic orifice.
3. Right lateral diaphragmatic nodes, situated near the

caval opening.
4. Left lateral diaphragmatic nodes, situated near the
esophageal opening.
Actions of Diaphragm
The diaphragm acts to subserve the following functions:
1. Muscle of inspiration: The diaphragm is the main/
principal muscle of respiration. When it contracts, it
descends and increases the vertical diameter of the
thoracic cavity (for details see page 223).
2. Muscle of abdominal staining: The contraction of
diaphragm along with contraction of muscles of anterior
abdominal wall raises the intra-abdominal pressure to
evacuate the pelvic contents (voluntary expulsive efforts,
e.g., micturition, defecation, vomiting, and parturition).
3. Muscle of weight lifting: By taking deep breath and
closing the glottis, if possible to raise the intraabdominal pressure to such an extent that it will help
support the vertebral column and prevent its flexion.
This assists the postvertebral muscles in lifting the
heavy weights.
4. Thoraco-muscular pump: The descent of diaphragm
decreases the intrathoracic pressure and at the same
time increases the intra-abdominal pressure. This
pressure change compresses the inferior vena cava, and
consequently its blood is forced upward into the right
atrium.
5. Sphincter of esophagus: The fibres of the right crus of
diaphragm subserve a sphincteric control over the
esophageal opening.
Diaphragmatic paralysis (paralysis of diaphragm):
The unilateral damage of phrenic nerve leads to
unilateral diaphragmatic paralysis. The condition is
diagnosed during fluoroscopy when an elevated
hemidiaphragm is seen on the side of lesion, and
showing paradoxical movements. The bilateral damage
of phrenic nerves leads to complete diaphragmatic
paralysis. It is a serious condition as it may cause
respiratory failure.
Hiccups: They occur due to involuntary spasmodic
contractions of the diaphragm accompanied by the
closure of the glottis. Hiccups normally occur after eating
or drinking as a result of gastric irritation.
The pathological causes of hiccups include
diaphragmatic irritation, phrenic nerve irritation, hysteria,
and uremia.
Development
The diaphragm develops in the region of neck from the
following four structures (Fig. 14.10):
1. Septum transversum, ventrally.
2. Pleuroperitoneal membranes at the sides.
3. Dorsal mesentery of esophagus, dorsally.
4. Body wall, peripherally.
Most probably

Central tendon of diaphragm develops from septum

transversum.
Domes of diaphragm develop from pleuroperitoneal
membrane.
Part of diaphragm around the esophagus develops from the
dorsal mesentery of esophagus.
Peripheral part of diaphragm, develops from the body

wall.
For details of development, consult any textbook of
Embryology.
N.B. The musculature of diaphragm develops from 3rd,

4th, and 5th cervical myotomes (C3, C4, C5), hence it
receives its motor innervations from C3, C4, and C5
spinal segments (i.e., phrenic nerve). Later, when
diaphragm descends from the neck to its definitive
position (i.e., thoraco-abdominal junction), its nerve
supply is dragged down. This explains the long course of
the phrenic nerve.
Compressed lung
Septum
transversum
Pleuroperitoneal
membrane
Coils of
intestine Herniated into
thoracic cavity
Spleen
Apparent
dextrocardia
Lung
Stomach herniating into

thoracic cavity
Liver
Body wall
Dorsal mesentery of
esophagus
Fig. 14.10 Developmental components of the diaphragm.
Diaphragmatic fascia
(endoabdominal fascia)
Fig. 14.11 Posterolateral hernia of diaphragm. (Source:

Fig. 17.8, Page 190, Textbook of Clinical Embryology,
Vishram Singh. Copyright Elsevier 2012, All rights reserved.)
Gastroesophageal
junction displaced
into chest
Phrenicoesophageal
ligament
Phrenicoesophageal
ligament
Diaphragm
Cardiac angle absent
Diaphragm
Peritoneum
Herniated stomach
Cardiac angle
A
B
Peritoneum
Fig. 14.12 Acquired hiatal (sliding) hernia: A, normal position of stomach; B, herniated stomach.
193
194
Diaphragmatic hernias
Congenital
The various types of congenital diaphragmatic hernias are
as follows:
1. Posterolateral
hernia
(commonest
congenital
diaphragmatic hernia; Fig. 14.11): In this condition, there
is herniation of abdominal contents into the thoracic
cavity, which compress the lung and heart. The herniation
occurs through the gap (pleuroperitoneal hiatus) between
the costal and vertebral origins of the diaphragm called
foramen of Bochdalek. The gap remains due to failure of
closure of pleuroperitoneal canal. It occurs commonly on
the left side (for details see Clinical and Surgical
Anatomy, 2nd edition by Vishram Singh).
2. Retrosternal hernia: It occurs through the gap between
the muscular slips of origin from xiphisternum and 7th
costal cartilage (space of Larry or foramen of Morgagni).
It is more common on the right side. Thus hernial sac
usually lies between pericardium and right pleura.
Usually it causes no symptoms in the infants, but in later
age, the patients complain of discomfort and dysphagia
(difficulty in swallowing).
3. Paraesophageal hernia: In this condition, there is defect
in the diaphragm to the right and anterior to the
esophageal opening. The anterior wall of the stomach
rolls upwards in the hernial sac through this defect, until

it becomes upside down in the thoracic cavity. An
important feature of paraesophageal hernia is that the
normal relationship of gastroesophageal junction in
relation to diaphragm is not disturbed.
Acquired
The acquired diaphragmatic hernias may be either traumatic
or hiatal (sliding).
1. Traumatic hernia: It may occur due to an open injury to
the diaphragm by the penetrating wounds or closed
injury to the diaphragm in road traffic accidents leading
to sudden severe increase in the intra-abdominal
pressure.
2. Hiatal (sliding) hernia (Fig. 14.12): This is the
commonest of all the internal hernias. In sliding hernia,
the gastroesophageal junction and cardiac end of
stomach slides up into the thoracic cavity, but only
anterolateral portion of the herniated stomach is
covered by peritoneum, therefore the stomach itself is
not within the hernial sac. The hiatal hernia is caused
by the weakness of the diaphragmatic muscle
surrounding the esophageal opening and increased
intra-abdominal pressure. This may cause regurgitation
of acid contents of stomach into the esophagus leading
to peptic esophagitis. The patient complains of heart
burn. The sliding hernia is usually associated with short
esophagus.
CHAPTER
15
Bones and Joints of

the Thorax
PARTS
BONES OF THE THORAX

The bones of the thorax form the major part of the thoracic
cage and provide support and protection to viscera (e.g.,
heart and lungs) present within the thoracic cavity. The
thoracic cage is not static in nature, but dynamic as it keeps
on moving at its various joints.
The bones of the thorax are:
1. Sternum.
2. Twelve pairs of ribs.
3. Twelve thoracic vertebrae.
STERNUM
The sternum (breast bone; Fig. 15.1A and B) is an elongated
flat bone, which lies in the anterior median part of the chest
wall. It is about 7 cm long.
The sternum consists of the following three parts:

1. Upper part, the manubrium sterni/episternum.
2. Middle part, the body/mesosternum.
3. Lower part, the xiphoid process/metasternum.
The sternum resembles a dagger or a small sword in shape.
Its three partsmanubrium, body, and xiphoid process
represent the handle, blade, and point of the sword,
respectively.
The upper part of sternum is broad and thick, whereas its
lower part is thin and pointed. Its anterior surface is slightly
rough and convex, while its posterior surface is smooth and
slightly concave.
The manubrium and body of sternum lie at an angle of
163 to each other, which increases slightly during
inspiration and decreases during expiration. The angle
Clavicular notch
Suprasternal notch
Notches for
costal cartilage
Clavicular notch
Notches for cartilages
1st
Manubrium
2nd
Manubrium
1st
Sternal angle
2nd
3rd
3rd
Body
4th
Body
4th
5th
5th
6th
Xiphisternal joint
7th
6th
7th
Xiphoid process
A
Xiphoid process
B
Fig. 15.1 Features of the sternum: A, anterior aspect; B, lateral aspect.
between long axis of manubrium and long axis of body of

sternum is about 17.

Anatomical Position
In anatomical position, the sternum as a whole is directed
downwards and inclined slightly forward with its rough
convex surface facing anteriorly. Its broad end is directed
upwards and lower pointed end is directed downwards.
Upper border is thick, rounded, and concave. It presents a

notch called suprasternal notch or jugular notch.
It provides attachment to the interclavicular ligament.
Clavicular notch on either side of suprasternal notch
articulates with the clavicle to form sternoclavicular joint.
FEATURES AND ATTACHMENTS

Manubrium (Episternum; Figs. 15.1 and 15.2)
It is roughly quadrilateral in shape. It lies opposite to the
third and fourth thoracic vertebrae. It is the thickest and
strongest part of the sternum and presents the following
features:
1. Two surfacesanterior and posterior.
2. Four borderssuperior, inferior, and lateral (right and
left).
Anterior surface on each side provides attachment to the
sternal head of sternocleidomastoid and pectoralis major
muscles.
Lateral border presents two articular facets:

Upper facet articulates with the 1st costal cartilage to form
primary cartilaginous joint.
Lower demifacet along with other demifacet in the body
of sternum articulates with the 2nd costal cartilage.
Lower border articulates with the upper end of the body of

sternum to form secondary cartilaginous joint called
manubriosternal joint. The manubrium makes a slight angle
with the body at this junction called sternal angle or angle of
Louis. It is recognized by the presence of a transverse ridge
on the anterior aspect of the sternum.
Body (Mesosternum; Figs 15.1 and 15.2)
Posterior surface is smooth and forms anterior boundary of

superior mediastinum.
On each side, it provides attachment to two muscles:
(a) sternohyoid at the level of clavicular notch, and
(b) sternothyroid at the level of facet for 1st costal
cartilage.
Sternal head of
sternocleidomastoid
Lower half is related to arch of aorta.

Upper half is related to three branches of the arch of aorta,
viz. brachiocephalic artery, left common carotid artery,
left subclavian artery, and left brachiocephalic vein.
The features of the body are as follows:

1. It is longer, narrower, and thinner than the manubrium.
2. It is broadest at its lower end.
3. Its upper end articulates with the manubrium at the
sternal angle to form manubriosternal joint.
Jugular notch
Sternohyoid
Clavicle
Clavicle
Sternothyroid
Sternal angle
Sternal angle
Pectoralis major
Area related to pleura
4th costal
cartilage
Lines of pleural reflection
Bare area of
pericardium
Sternocostalis
Rectus
abdominis
Fig. 15.2 Attachments on the sternum: A, anterior surface; B, posterior surface.
Diaphragm
197
198
4. Its lower end articulates with the xiphoid process to

form primary cartilaginous xiphisternal joint.
5. Its anterior surface presents three faint transverse ridges
indicating the lines of fusion of four small segments
called sternebrae. The anterior surface on each side gives
origin to the pectoralis major muscle.
6. Its posterior surface is smooth and slightly concave.
(a) Lower part of posterior surface gives origin to
sternocostalis muscle.
(b) On the right side of median plane, posterior surface
is related to pleura, which separates it from the lung.
(c) On the left side of median plane, upper half of the
body is related to the pleura and lower half to the
pericardium (bare area of the pericardium)
7. Its lateral border articulates with the 2nd7th costal
cartilages (to form synovial joints. Strictly speaking, 2nd
costal cartilage articulates at the side of manubriosternal
junction and 7th costal cartilage articulates at the
xiphisternal junction).
Xiphoid Process (Metasternum; Figs 15.1 and 15.2)

1.
2.
3.
4.
It is the lowest and smallest part of the sternum.

It varies greatly in size and shape.
It may be bifid or perforated.
Its anterior surface provides insertion to the medial
fibres of the rectus abdominis.
5. Its posterior surface gives origin to the sternal fibres of
the diaphragm.
6. Its tip provides attachment to the upper end of linea
alba.
Muscles attached on the posterior and anterior surfaces of
sternum are summarized below:
Muscle attached on the
anterior surface of the
sternum
Muscles attached on the

posterior surface of the
sternum
Sternal head of
Sternohyoid
sternocleidomastoid
Sternothyroid
Pectoralis major
Sternocostalis
Rectus abdominis
Diaphragm (sternal fibres)
N.B. Features of interest at the sternal angle: Sternal angle

can be felt as a transverse ridge on the sternum about 5cm
below the suprasternal notch. The sternal angle is an
important surface bony landmark for many anatomical
events accurate this level. These are:
Second costal cartilage articulates, on either side, with
the sternum at this level, hence this level is used for
counting the ribs.
It lies at the level of intervertebral disc between T4 and
T5 vertebrae.
Horizontal plane passing through this level separates

superior mediastinum from inferior mediastinum.
Ascending aorta ends at this level.
Arch of aorta begins and ends at this level.
Descending aorta begins at this level.
Trachea bifurcates into right and left principal bronchi at
this level.
Pulmonary trunk divides into right and left pulmonary
arteries at this level.
Upper border of heart lies at this level.
Azygos vein arches over the root of right lung to end in
the superior vena cava.
Sternal puncture: Manubrium sterni is the preferred site for
bone marrow aspiration because it is subcutaneous and
readily accessible. The bone marrow sample is required for
hematological examination. A thick needle is inserted into
the upper part of manubrium to avoid injury to arch of aorta
which lies behind the lower part. Sternal puncture is not
advisable in children because in them the plates of compact
bone of sternum are very thin and if needle passes through
and through the manubrium it will damage the arch of aorta
and its branches, leading to fatal hemorrhage.
Mid-sternotomy: To gain access to the mediastinum for
surgical operations on heart and great blood vessels, the
sternum is often divided in the median plane called midsternotomy.
Funnel chest (pectus excavatum): It is an abnormal
shape of thoracic cage in which chest is compressed
anteroposteriorly and sternum is pushed backward by the
overgrowth of the ribs and may compress the heart.
Pigeon chest (pectus carinatum): It is an abnormal
shape of thoracic cage in which chest is compressed from
side-to-side and sternum projects forward and downward
like a keel of a boat.
Sternal fracture: It is common in automobile accidents;
e.g., when the drivers chest is hit against the steering
wheel, the sternum is often fractured at the sternal angle.
The backward displacement of fractured fragments may
damage aorta, heart, or liver and cause severe bleeding
which may prove fatal.
OSSIFICATION
The sternum develops from two vertical cartilaginous plates
(sternal plates), which fuse in the midline.
The sternum ossifies from six double centres, viz.
1. One for manubrium.
2. Four for body.
3. One for xiphoid process.
Appearance
The centers appear in descending order for different parts of
sternum as follows:
1. Manubrium: 5th month

2. Body
(a) First sternebra: 6th month
(b) Second sternebra: 7th month
(c) Third sternebra: 8th month
(d) Fourth sternebra: 9th month
3. Xiphoid process: 3rd year
Line joining the anterior and

posterior ends of the costal
arch
of IUL*
Fusion
The fusion occurs as follows:
1. Fusion between sternal plates takes place from below
upwards. It begins at puberty and completed by 25 years.
2. The xiphoid process fuses with the body at the age of 40
years.
3. Manubrium does not fuse with the body. As a result, the
secondary cartilaginous manubriosternal joint usually
persists throughout life. In about 10% individuals,
fusion occurs in old age.
Sternal foramen and cleft sternum: The two sternal plates
fuse in caudocranial direction. Sometimes sternebrae fail to
fuse in the midline, as a result defect occurs in the body of
sternum in the form of sternal foramen or cleft sternum. The
cleft sternum is often associated with ectopia cordis.
RIBS
The ribs are flat, ribbon-like, elastic bony arches, which
extend from thoracic vertebrae posteriorly to the lateral
borders of the sternum anteriorly. Their anterior ends are
connected to the costal cartilage. The ribs along with its
costal cartilage constitute the costa. The ribs and their costal
cartilages form greater part of the thoracic skeleton.
Number
Normally there are 12 pairs of ribs (but occurrence of
accessory cervical or lumbar rib may increase them to 13
pairs or absence of 12th rib may reduce them to 11 pairs).
Costal arch
Fig. 15.3 Costal arch (side view).
4. The ribs are arranged obliquely, i.e., their anterior ends

lie at lower level than their posterior ends (Fig. 15.3).
5. The obliquity of ribs increases progressively from 1st to
9th rib, hence 9th rib is most obliquely placed.
6. The width of ribs gradually reduced from above
downward.
The anterior ends of first seven ribs are connected to the
sternum through their costal cartilages. The cartilages at the
anterior ends of 8th, 9th, and 10th ribs are joined to the next
higher cartilage. The anterior ends of 11th and 12th ribs are
free and therefore called floating ribs.
N.B.
The 10th rib usually have free anterior ends in Japanese.
First rib slopes downwards along its entire extent.
The middle of each costal arch (consisting of a rib and its
costal cartilage) except the first rib lies at a lower level
than a straight line joining the two ends of the costa
(Fig. 15.3).
CLASSIFICATION
A. According to features
1. Typical ribs: 3rd9th.
2. Atypical ribs: 1st, 2nd, 10th, 11th, and 12th.
The typical ribs have same general features, whereas the
atypical ribs have special features and therefore can be
differentiated from the remaining ribs.
Arrangement and General Outline
B. According to relation with the sternum
1. The ribs are arranged one below the other and the gaps
between the adjacent ribs are called intercostals spaces.
2. The length of ribs increases from 1st to 7th rib and then
gradually decreases; hence, seventh rib is the longest rib.
3. The transverse diameter of thorax increases progressively
from 1st to 8th rib, hence 8th rib has the greatest lateral
projection.
1. True ribs: 1st7th (i.e., upper 7 ribs).

2. False ribs: 8th12th (i.e., lower 5 ribs).
*Intrauterine life.
True ribs articulate with the sternum anteriorly, whereas

false ribs do not articulate with the sternum anteriorly.
C. According to articulation
1. Vertebrosternal ribs: 1st7th.
2. Vertebrochondral ribs: 8th10th.
3. Vertebral (floating) ribs: 11th and 12th.
199
200
The vertebrosternal ribs articulate posteriorly with vertebrae

and anteriorly with the sternum.
The vertebrochondral ribs articulate posteriorly with
vertebrae and anteriorly their cartilages join the cartilage of
the higher rib.
The vertebral or floating ribs articulate posteriorly with
the vertebrae but their anterior ends are free.
Side Determination and Anatomical Position

The side of the rib can be determined by holding it in such a
way that its posterior end having head, neck, and tubercle is
directed posteriorly, its concavity faces medially and its sharp
border is directed inferiorly.
In an anatomical position, the posterior end is higher and
nearer the median plane than the anterior end.
TYPICAL RIBS (Fig. 15.4)
Features and Attachments

Anterior (costal) end
It bears a small cup-shaped depression, which joins the
corresponding costal cartilage to form a primary
cartilaginous costochondral joint.
Parts
Each rib has three parts: (a) anterior end, (b) posterior end,
and (c) shaft.
The anterior end bears a concave depression.
The posterior end consists of head, neck, and tubercle.
The shaft is the longest part and extends between anterior
and posterior ends. It is flattened and has inner and outer
surfaces and upper and lower borders. It is curved with
convexity directed outwards and bears a costal groove on its
inner surface near the lower border. Five centimeters away
from tubercle, it abruptly changes its direction, this is called
angle of the rib.
Tubercle
Posterior end
It presents head, neck, and tubercle.
Head
It has two articular facets: lower and upper.
1. The lower larger facet articulates with the body of
numerically corresponding vertebra.
2. The upper smaller facet articulates with the next higher
vertebra.
The crest separating the two articular facets lies
opposite the intervertebral disc.
Neck
Articular part
Non-articular part
Neck
Head
5 cm
Upper
articular facet
Angle of
the rib
Crest for
intra-articular
ligament
Oblique
line
Outer
surface
Lower
articular facet
Inner surface
Shaft
Costal groove
1. It lies in front of the transverse process of the

corresponding vertebra.
2. It has two borderssuperior and inferior, and two
surfacesanterior and posterior.
3. The upper border is sharp crest like, whereas the lower
border is rounded.
4. The posterior surface is rough and pierced by foramina.
Tubercle
1. It is situated on the outer surface of the rib at the
junction of neck and shaft.
2. It is divided into two partsmedial articular part and
lateral non-articular part. The articular part bears a small
oval facet, which articulates with the transverse process
of corresponding vertebra. The non-articular part is
rough and provides attachment to ligaments.
Shaft
Lower border
Upper border
Cup-shaped
small depression
for costal cartilage
Anterior end of rib
Fig. 15.4 Features of a typical rib.
1. It is thin and flattened.

2. It presents two surfacesouter and inner, two
bordersupper and lower, and two anglesposterior
and anterior.
Borders
Superior border
The superior border is thick and rounded, and presents outer
and inner lips:
202
Side Determination
Side of the first rib can be determined by holding the rib in
such a way that:
(a) its larger end is directed anteriorly and its smaller end is
directed posteriorly,
(b) the surface of its shaft having two grooves separated by a
ridge is directed superiorly, and
(c) its concave border is directed inwards and its convex
border is directed outwards.
N.B. Trick for students for side determination of first rib:
Keep the rib on the table top considering its position in your
own body. Now note that the rib belongs to the side on
which its both ends touch the surface. If the rib is placed on
the wrong side, then only its anterior end will be touching
the surface.

Inner border
1. It presents a scalene tubercle about its middle. Tubercle
and adjoining part of the upper surface provides
attachment to the scalenus anterior muscle.
2. It provides attachment to the Sibsons fascia (suprapleural
membrane).
Outer border
It provides origin to the first digitation of serratus anterior
about its middle, just behind the groove for the subclavian
artery.
Superior (upper) surface
1.
It is crossed obliquely by two shallow grooves (anterior

and posterior) separated by a slight ridge. The ridge is
continuous with the scalene tubercle. The anterior groove
lodges subclavian vein, while posterior groove lodges the
subclavian artery and lower trunk of the brachial plexus.
2. The area behind posterior groove up to the costal tubercle
provides attachment to the scalenus medius muscle.
3. The area in front anterior groove and near the anterior
end provides attachment to subclavius muscle
(anteriorly) and costoclavicular ligament (posteriorly).
Lower surface
It is related to the costal pleura.
Neck
1. It is elongated and directed upwards, backwards, and
laterally.
2. The following structures form anterior relations of neck
from medial to lateral side:
(a) Sympathetic chain
(b) First posterior intercostal Vein
(c) Superior intercostal Artery
(d) Ventral ramus of first thoracic Nerve.
Memory device: Chain pulling the VAN.
Second Rib (Fig. 15.6)

Distinguishing Features and Attachments
1. Its length is twice that of the second rib.
2. Its shaft is sharply/highly curved.
3. Its shaft is not twisted; hence both the ends of rib touch
the table top when placed on it.
4. Near its middle, the outer convex surface of shaft
presents a rough impression or prominent tubercle,
which provides attachment to the serratus anterior
muscle (lower part of first and whole of second
digitation).
5. The outer surface of the shaft is directed outwards and
upwards, while inner surface of the shaft is directed
inwards and downwards.
6. Posterior part of internal surface presents a short costal
groove.
7. The upper border and adjoining part of upper surface
provide attachment to the scalenus posterior and
serratus posterior superior muscles.
Tenth Rib
Distinguishing Features
It has single articular facet on its head, which articulates with
the body of corresponding thoracic vertebra.
It is slightly shorter than the typical rib.
Eleventh Rib
1.
2.
3.
4.
5.
6.
It has single large, articular facet on its head.

It has no neck and no tubercle.
Its anterior end is pointed and tipped with cartilage.
It has slight angle and a shallow costal groove.
Its inner surface is directed upwards and inwards.
It has a slight angle.
Twelfth Rib (Fig. 15.7)

The 12th rib has the same features as the 11th except that:
1. It has no angle.
2. It has no costal groove.
3. It is much shorter than 11th.
Side Determination
The side of 12th rib can be determined by keeping the rib in
such a way that:
1. Its pointed anterior end is directed anterolaterally and
its broader end posteromedially.
2. Its slightly concave surface faces inwards and upwards.
3. Its sharper border is directed inferiorly.
204
Upper border
The upper border provides attachment to the external and
internal intercostal muscles.
OSSIFICATION

All the ribs ossify by four centers except 1st, 11th, and
12th ossify,
(a) One primary center for shaft.
(b) Three secondary centers: one for head, one for
articular part of tubercle and one for non-articular
part of the tubercle.
First rib ossifies by three centers: one primary centre for
shaft and two secondary centersone for head and one
for tubercle.
Eleventh and 12th ribs ossify by two centers each: one
primary center for the shaft and one secondary centre for
the head.
Primary centers of all the ribs appear at the 8th week of
IUL.
Secondary centers of all the ribs appear at puberty.
Fusion in all the ribs occurs at the age of 20 years.
THORACIC VERTEBRAE
There are 12 thoracic vertebrae. They are identified by the
presence of costal facet/facets on the sides of their bodies for
articulation with the heads of the ribs. These articulations are
characteristic of thoracic vertebrae as they are not found in
the cervical lumbar and sacral vertebrae. The size of thoracic
vertebrae increases gradually from above downwards.
The bodies of upper thoracic vertebrae is gradually
changed from cervical to thoracic type and those of lower
from thoracic to lumbar type. Thus the body of T1 vertebra
is typically cervical in type and that of T12 vertebra is
typically lumbar in type.
N.B. Presence of the articular facet(s) on the side of the
body is the cardinal feature of the thoracic vertebrae.
CLASSIFICATION
According to the features, the thoracic vertebrae are classified
into two types:
1. Typical: second to eighth.
2. Atypical: first and ninth to twelfth.
Cervical rib: The costal element of the C7 vertebra may
elongate to form a cervical rib in about 5% individuals. The
condition may be unilateral or bilateral. It occurs more often
unilaterally and somewhat more frequently on the right
side. The cervical rib may have a blind tip or the tip may be
connected to the 1st rib by fibrous band or cartilage or
bone. It may compress the lower trunk of brachial plexus
and subclavian artery. The compression produces: (a) pain
along the medial side of forearm and hand and
(b) disturbance in the circulation of the upper limb (for detail
see Clinical and Surgical Anatomy by Vishram Singh.)
Lumbar rib (Gorilla rib): It develops from the costal
element of L1 vertebra. Its incidence is more common
than the cervical rib, but remains undiagnosed as it
usually does not cause symptoms. It may be confused
with the fracture of transverse process of L1 vertebra.
Fracture of rib: Usually the middle ribs are involved in the
fracture. The rib commonly fractures at its angle (posterior
angle) as it is the weakest point.
Flail chest (stove-in-chest): When ribs are fractured at
two sites (e.g., anteriorly as well as at an angle), the flail
chest occurs. The flail segments of ribs are sucked in during
inspiration and pushed out during expiration leading to a
clinical condition called paradoxical respiration).
N.B.
Fracture of ribs is rare in children as the ribs are elastic in
them.
First two ribs (1st and 2nd ribs) are protected by clavicle
and last two ribs (11th and 12th) are mobile (floating),
hence they are rarely injured.
TYPICAL THORACIC VERTEBRAE

Characteristic Features (Fig. 15.8)
1. Presence of articular facets on each side of the body and
on front of transverse processes for articulation with the
ribs.
2. Body is heart shaped, particularly in the midthoracic
region when viewed from above. Its transverse and
anteroposterior measurements are almost equal.
3. Vertebral foramen is circular.
4. Spinous process is long, slender, and directed downwards.
5. Pedicle is attached to the upper part of the body, thus
making the inferior vertebral notch deeper.
Parts
The thoracic vertebra consists of two parts:
1. Body.
2. Vertebral arch.
The body and vertebral arch enclose a vertebral foramen
in which lies the spinal cord surrounded by its meninges.
Body
1. It is heart shaped, when viewed from above.
2. Its anteroposterior and transverse dimensions are almost
equal.
3. On each side, the bodies are two costal facets, superior,
and inferior.
Lamina
Transverse process
Spine
Articular facet for

tubercle of the rib
Vertebral foramen
Transverse process
Superior
articular process
Body
Articular facet
for tubercle
of the rib
Pedicle
Costal facet for
the head of rib
Spine
Inferior costal
facet
Inferior vertebral notch
Inferior articular process
Superior articular
process
Superior
costal facet
Fig. 15.8 Features of a typical thoracic vertebra: A, superior view; B, lateral view.

Superior facet is larger and situated near the upper

border of the body in front of the root of the pedicle.
Inferior facet is smaller and situated near the lower
border in front of the inferior vertebral notch.
Vertebral arch: It consists of a pair of pedicles anteriorly and

two laminae, posteriorly:

The pedicles (right and left) are short rounded bony bars,
which project backwards and laterally from the posterior
aspect of the body.
The laminae (right and left)each pedicle continues
posteromedially as a vertical plate of bone. The laminae of
two sides join with each other in the posterior midline.
The spinous process arises in the midline where the two
laminae meet posteriorly.
Two transverse processes, one on either side arises from the
junction of pedicle and lamina.
Two paired articular process, two on each side spring from
lamina, the superior articular process project rather more
from pedicle than lamina, the inferior articular process
springs from a lamina.

Body
1. The upper larger costal facet (actually demifacet)
articulates with the head of the numerically
corresponding rib.
2. The lower smaller costal facet (actually demifacet)
articulates with the head of the next lower rib.
3. Anterior and posterior surfaces of body provide
attachment to the anterior and posterior longitudinal
ligaments, respectively. These ligaments are attached to
both the upper end lower borders of the body.
4. Posterior surface of body is marked by vascular foramina
for basivertebral veins, which are covered by the posterior
longitudinal ligament.
Pedicles
1. They are attached nearer the superior border of body, as
a result the superior vertebral notch is shallow and the
inferior vertebral notch is deep.
2. The deep inferior vertebral notch together with small
superior vertebral notch of next lower vertebra
completes the intervertebral foramen, through which
spinal nerve leaves the vertebral canal.
Laminae
1. They are short, broad, and thick; and overlap each other
from above downwards.
2. Their margins give attachment to the ligamenta flava.
Superior Articular Processes
The articular facets on superior articular process are directed
backwards and slightly laterally and articulate with the
inferior articular facet of the next higher vertebra.
Inferior Articular Processes
The articular facet on inferior articular process is flat and
faces forwards and little downwards and medially. It
articulates with the superior articular facet of the next lower
vertebra.
Transverse Processes
They are large club shaped and projects laterally and slightly
backwards.
The facet on the anterior aspect of the tip of transverse

process articulates with the tubercle of the numerically
corresponding rib.
They provide attachments to the ligaments and muscles
related to the rib cage and back.
Spine
The spines are directed downwards and backwards. The
spinous processes of middle four vertebrae (i.e., from 5th to
205
206
T1
T2
the back of the root of neck just below the lower end of
median nuchal furrow.
The spinous process of T8 vertebra is longest.
Upper 4 spines
T3
T4
The backward slant decreases. At the 11th vertebra, the

spine is directed almost downwards. It is termed anticlinical
vertebra, below this level spine slants dorsally and backwards.
The spines provide attachment to the supraspinous and
interspinous ligaments.
T5
T6
T7
Middle 4 spines
T8
T9
N.B. The spines of middle four thoracic vertebrae are

almost horizontal.
T10
T11
T12
Lower 4 spines
ATYPICAL THORACIC VERTEBRAE (Fig. 15.10)

Fig. 15.9 Showing inclination of the spinous processes of
thoracic vertebrae.
8th) are very long, vertical, and overlap each other. The
spinous processes of upper four and lower four vertebrae are
relatively short and less oblique in direction (Fig. 15.9).
N.B.
The spinous process of T1 vertebra is most prominent
and horizontal in its projection and can be palpated at
T1
T1
First Thoracic Vertebra

1. It resembles the 7th cervical vertebra.
2. The body is narrow anteroposteriorly. Its upper surface
is concave from side to side with an upward projecting
lip on either sides. The anterior border of inferior surface
projects downwards.
3. The superior articular facet on the side of the body is
circular and articulates with the whole of the facet on
the head of the first rib.
ATYPICAL FEATURES
Body cervical in type
Superior costal facet on the side of body circular
Deep superior vertebral notch
Horizontal long spine
Only superior costal demifacet on the side of body
T9
T9
T10
T10 Only superior large costal facet (semilunar/oval) on the

side of body encroaching the upper part of pedicle
T11
T12
Fig. 15.10 Features of atypical thoracic vertebrae.
T11 Only single circular costal facet on the side of

body extending on the root of pedicle
No articular facet on the transverse process
T12 Resembles L1 vertebra
Transverse process small with three tubercles
No articular facet on transverse process
Only single large costal facet on the side of pedicle
Articular facet on inferior articular process everted
4. The superior vertebral notches are deep (i.e., clearly

seen) as in cervical vertebra.
5. The inferior articular facet is half (i.e., demifacet)
articulates with the head of the 2nd rib.
6. The spinal process is nearly horizontal.
Table 15.1 Distinguishing features atypical thoracic

vertebrae
Vertebra
Distinguishing features
T1
Resembles 7th cervical vertebra

Superior costal facet is circular
Superior vertebral notch is deep and clearly seen
Ninth Thoracic Vertebra
T9
Presence of only superior demifacet
T10
Presence of only single large complete costal facet
1. The lower costal facet on each side of body is absent

2. The body on each side possesses only superior costal
facet (demifacet) for articulation with the 9th rib.
T11
Presence of single large circular costal facet

Absence of articular facet on transverse process
T12
Resembles 1st lumbar vertebra

Presence of single large circular facet extending
onto the root of tubercle
Tenth Thoracic Vertebra
Transverse process presents three tubercles:
superior, inferior, and lateral
The body on each side possesses only single articular facet,
which is semilunar or oval for articulation with the 10th
rib. The costal facet encroaches on the upper part of the
pedicle.
Eleventh Thoracic Vertebra

1. Body on each side possesses single large circular costal
facet for articulation with the head of the 11th rib. The
costal facet extends onto the root of the pedicle.
2. Transverse processes are small and do not present costal
facet on their tips (as 11th rib has no tubercle).
COSTAL CARTILAGES
The costal cartilages are made up of hyaline cartilage and are
mainly responsible for providing elasticity and mobility of
the chest wall.
First to 7th cartilages connect the respective ribs with the
lateral border of the sternum and they increase in length
from 1st to 7th.
Eighth to 10th cartilages at their anterior ends are
connected with the lower border of the cartilage above and
there is a gradual decrease in length from 8th to 10th.
Eleventh and 12th cartilages end in free pointed
extremities.
Twelfth Thoracic Vertebra
JOINTS OF THE THORAX
1. It resembles the first lumbar vertebra.
2. Body on each side possesses a large single costal facet,
which is more on the lower part of the pedicle than on
the body.
3. Transverse process is small and presents three tubercles
superior, middle, and inferior. It has no articular facet
(as 12th rib has no tubercle).
The joints of thorax are as follows:

1.
2.
3.
4.
5.
6.
Costovertebral.
Costotransverse.
Costochondral.
Interchondral.
Manubriosternal.
Intervertebral.
The three tubercles of the transverse process of 12th

thoracic vertebra correspond with the following processes of
the lumbar vertebra:
COSTOVERTEBRAL JOINTS (Fig. 15.11)
(a) Superior tubercle corresponds to the mamillary process

of lumbar vertebra.
(b) Middle tubercle corresponds to the true transverse
process of lumbar vertebra.
(c) Inferior tubercle corresponds to the accessory process of
the lumbar vertebra.
These joints are formed by articulation of articular facets on

the head of ribs and costal facets on the bodies of thoracic
vertebrae.
The head of typical rib articulates with the body of
numerically corresponding vertebra and also with the body
of next higher vertebra.
The important distinguishing features of atypical thoracic

vertebrae (i.e., 1st, 9th, 10th, 11th, and 12th) are enumerated
in Table 15.1.
Type
Synovial type of plane joint.
207
It is a secondary cartilaginous joint (symphysis) between

manubrium and body of sternum. It permits slight sliding
movements of body of sternum on the manubrium during
respiration.
N.B. The manubriosternal joint is not a typical symphysis
because as a rule bones taking part in the formation of a
symphysis do not undergo bony union, but in many
individuals after 30 years of age bony union does take place
between the manubrium and the body of sternum.
Arc
Articular process
INTERVERTEBRAL JOINTS
The intervertebral joints are formed
Fig. 15.13 The articular processes of thoracic vertebra are

set on an arc.
(a) between the bodies of the vertebrae, and

(b) between the articular processes of the vertebra.
JOINTS BETWEEN THE BODIES OF THE VERTEBRAE

These are secondary cartilaginous joint. The inferior and
superior surfaces of the adjacent vertebral bodies are covered
by thin plates of hyaline cartilages, which in turn are united
by fibrocartilaginous intervertebral disc. The disc consists of
an outer rim by fibrocartilagethe annulus fibrosus and a
central core of gelatinous substancethe nucleus pulposus.
These joints are held together by anterior and posterior
longitudinal ligaments of the vertebral column (for details
see General Anatomy by Vishram Singh).
JOINTS BETWEEN THE ARTICULAR PROCESSES

The joints between the superior and inferior articular
processes of adjacent vertebrae are called facet (zygapophysial)
joints. They are plane type of synovial joints and permit

gliding movements. The zygapophysial joints of thoracic
vertebrae are directed vertically. This limits flexion and
extension, but facilitates rotation. The rotation is greatly
facilitated because the articular process of thoracic vertebrae
are set on an arc (Fig. 15.13). The ligaments are joint capsule,
which encloses the articular surfaces. The accessory
ligaments are: (a) ligaments flava between the laminae of
adjacent vertebrae, (b) supraspinous, (c) infraspinous, and
(d) intertransverse ligaments.
Movements
The movements of flexion and extension are best permitted
in the cervical and the lumbar regions, while the rotatory
movements are best seen in the thoracic region.
209
CHAPTER
16
Thoracic Wall and

Mechanism of
Respiration
The thoracic wall is formed posteriorly by the thoracic part

of the vertebral column, anteriorly by the sternum and costal
cartilages, and laterally by the ribs and the intercostal spaces.
The floor of thorax is formed by the diaphragm and its roof
is formed by suprapleural membranes. The diseases of
thoracic viscera are the leading cause of death all over the
world. Therefore, surface landmarks of the thorax are
extremely important to the physicians in providing reference
locations for performing inspection (visual observation),
palpation (feeling with firm pressure), percussion (detecting
densities through tapping), and auscultation (listening
sounds with the stethoscope).
SURFACE LANDMARKS
BONY LANDMARKS
4. Costal margin: It forms the lower boundary of the

thorax on each side and is formed by the cartilages of the
7th, 8th, 9th, and 10th ribs and the free ends of 11th and
12th ribs. The lowest point of costal margin is formed by
the 10th rib and lies at the level of L3 vertebra.
5. Subcostal angle: It is situated at the inferior end of the
sternum between the sternal attachments of the 7th
costal cartilage.
6. Thoracic vertebral spines: The first prominent spine
felt at the lower end of nuchal furrow (midline furrow
on the back of neck) is the spine of C7 vertebra
(vertebra prominens). All the thoracic spines are
counted below this level. For reference, the 3rd thoracic
spine lies at the level of root of spine of scapula and 7th
thoracic spine lies at the level of inferior angle of the
scapula.
The bony landmarks of the thoracic wall are as follows

(Fig. 16.1):
SOFT TISSUE LANDMARKS
1. Suprasternal notch (jugular notch): It is felt just above

the superior border of the manubrium sterni between
the proximal medial ends of the two clavicles. It lies at
the level of lower border of the body of T2 vertebra. The
trachea can be palpated in this notch.
2. Sternal angle (angle of Louis): It is felt as a transverse
ridge about 5 cm below the suprasternal notch. It marks
the angle made between the manubrium and the body
of the sternum (the angle between the long axis of
manubrium and body of sternum is 163 posteriorly
and 17 anteriorly). It lies at the level of intervertebral
disc between the T4 and T5 vertebrae. The 2nd rib
articulates on the either side with the sternum at this
level. Hence it used as surface landmark for counting the
ribs (for details see page 198).
3. Xiphisternal joint: It can be felt at the apex infrasternal/
subcostal angle formed by the meeting of anterior end
of subcostal margins. The xiphisternal joint lies at the
level of the upper border of the body of T9 vertebra.
1. Nipple: In males, the nipple is usually located in the 4th

intercostal space about 4 in (10 cm) from the midsternal
line. In females, its position varies considerably.
2. Apex beat of the heart: It is lowermost and outermost
thrust of cardiac pulsation, which is felt in the left 5th
intercostal space 3.5 in (9 cm) from the midsternal line
or just medial to the midclavicular line.
LINES OF ORIENTATION (Fig. 16.1)

The following imaginary lines are often used to describe
surface locations on the anterior and posterior chest wall.
1. Midsternal line: It runs vertically downwards in the
median plane on the anterior aspect of the sternum.
2. Midclavicular line: It runs vertically downwards from
the midpoint of the clavicle to the midinguinal point. It
crosses the tip of the 9th costal cartilage.
3. Anterior axillary line: It runs vertically downwards from
the anterior axillary fold.
212
2nd rib
Suprasternal
notch
Sternal angle
Nipple
T3
Midsternal
line
Anterior
axillary line
C7
7th rib
Clavicle
Spine of
scapula
Inferior angle of
scapula
T7
Scapular
line
Midclavicular
line
Costal margin
Xiphisternal
joint
A
Subcostal
angle
Inferior angle
of scapula
Posterior
axillary line
Fig. 16.1 Surface landmarks on the thoracic wall: A, anterior aspect; B, posterior aspect.
4. Midaxillary line: It runs vertically downwards from the

point in the axilla located between the anterior and
posterior axillary folds.
5. Posterior axillary line: It runs vertically downwards
from the posterior axillary fold.
6. Scapular line: It runs vertically downwards on the
posterior aspect of the chest passing through the inferior
angle of the scapula with arms at the sides of the body.
COVERINGS OF THE THORACIC WALL

The thoracic wall is covered from superficial to deep by:
1.
2.
3.
4.
Skin.
Superficial fascia.
Deep fascia.
Muscles.
Skin: The skin covering thoracic wall is thin on its anterior

aspect and thick on its back aspect. The distribution of hair
is variable and depends on the age, sex, and race.
Cutaneous nerves: The cutaneous innervation on the front
of thorax is provided by cutaneous branches of anterior
primary rami of thoracic spinal nerves (T2 T6) in sequence
from above downwards by the T2 at the level of 2nd rib to
the T6 at the level of xiphoid process. The skin above the
level of 2nd rib is supplied by the anterior primary ramus of
C4 via supraclavicular nerves.
N.B.
The anterior rami of C5T1 innervate the skin of the
upper limb.
The cutaneous innervation on the back of thorax (on
either side of midline for about 5 cm) is provided by
posterior rami of thoracic spinal nerves.
Superficial fascia: The superficial fascia is more dense on

the posterior aspect of the chest to sustain the pressure of
the body when lying in the supine position. The superficial
fascia on the front of the chest contains breast (mammary
gland), which is rudimentary in males and well-developed
in adult females. The breast is described in detail in
Chapter 3.
Deep fascia: The deep fascia is thin and ill-defined (except in
pectoral region) to allow free movement of the thoracic wall
during breathing.
Muscles: The thoracic wall is liberally covered by the
following extrinsic muscles:
1. Muscles of upper limb:
(a) Pectoralis major and pectoralis minor muscles cover
the front of thoracic wall.
(b) Serratus anterior covers the side of thoracic wall.
2. Muscles of abdomen: Rectus abdominis and external
oblique covers the lower part of the front of thoracic
wall.
3. Muscles of back:
(a) Trapezius and latissimus dorsi.
(b) Levator scapulae, rhomboideus major and minor.
(c) Serratusposterior, superior, and inferior.
(d) Erector spinae.
N.B.
The thoracic wall is more or less completely covered by
extrinsic muscles except in the anterior and posterior
median lines.
On the back, the thoracic wall is thinly covered by
musculature in the region of triangle of auscultation (see
page 62).
Actions: Depressor of the ribs.

Sternocostalis (Fig. 16.2B)
The sternocostalis muscle one on either side is situated on
the inner aspect of front of the chest wall (behind the
sternum and costal cartilages) occupying the anterior part of
the upper intercostal spaces, except the first space. The
sternocostalis muscle intervenes between the anterior end of
the intercostal nerves and the pleura.
Origin: It arises from the tip of transverse process from 7th

to 11th thoracic vertebrae.
Insertion: Each muscle passes obliquely downwards and
laterally to be inserted on to the upper edge and outer surface
of the rib immediately below in the interval between the
tubercle and angle.
Actions
Origin: It arises from (a) lower one-third of the posterior

surface of the body of sternum, (b) posterior surface of the
xiphoid process of the sternum, and (c) posterior surface of
the costal cartilages of lower three or four ribs.
1. Elevate and rotate the neck of rib in a forward

direction.
2. Are rotators and lateral flexors of the vertebral
column?
Insertion: The fibres diverge upwards and laterally as slips to

be inserted into the lower border and inner surfaces of the
costal cartilages of 2nd6th ribs.
The origin insertion, extent, direction of fibres, nerve

supply, and actions are given in Table 16.1.
INTERCOSTAL SPACES
Nerve supply: By intercostal nerves.

Action: It draws down the costal cartilages in which it is
inserted.
Levatores Costarum (12 Pairs)

These are a series of 12 small muscles placed on either side of
the back of thorax, just lateral to the vertebral column.
The spaces between the two adjacent ribs (and their costal
cartilages) are known as intercostal spaces. Thus there are 11
intercostal spaces on either side.
The 3rd6th spaces are typical intercostal spaces because
the blood and nerve supply of 3rd6th intercostal spaces is
confined only to thorax.
Table 16.1 Intrinsic muscles of the thoracic wall

Muscle
Origin
Insertion
Extent
Direction of fibres
Nerve supply
Actions
1. External
intercostal
Lower border of rib above
Upper border
(outer lip) of
rib below
From costochondral
junction to tubercle of
rib (anteriorly it
continues as anterior
intercostal membrane)
Downwards,
forwards, and
medially
Intercostal
nerve of the
same space
Elevates the
rib during
inspiration
2. Internal
intercostal
Floor of the costal groove of Upper border

the rib above
(inner lip) of
rib below
From lateral border of Upwards, forwards

sternum to the angle of and medially
rib (posteriorly it
continues as posterior
intercostal membrane)
Intercostal
Elevates the
nerve of same rib during
space
expiration
(a) Intercostalis
intimus
Inner surface of rib above
Inner surface
of rib below
Confined to the middle Upwards, forwards

2/4th of the intercostal and medially
space
Intercostal
Elevates the
nerve of same rib during
space
expiration
(b) Subcostalis
Inner surface of rib near

angle
Inner surface
of 2nd or 3rd
ribs below
Confined to posterior
parts of lower spaces
only
Upwards, forwards
and medially
Intercostal
nerves
Depressor of
ribs
(c) Sternocostalis
Lower 1/3rd of the

posterior surface of the
body of sternum
Posterior surface of
xiphoid process
Posterior surface of costal
cartilages of lower 3 or
4ribs near sternum
Costal
Inner surface of front
cartilages 2nd wall of chest
to 6th ribs
Upwards and
laterally
Intercostal
nerves
Draws 2nd
to 6th
cartilages
downwards
3. Transversus
thoracis
215
216
CONTENTS OF A TYPICAL INTERCOSTAL SPACE

Each space contains the following structures (Fig. 16.4):
1. Three intercostal muscles, viz.
(a) External intercostal.
(b) Internal intercostal.
(c) Innermost intercostal (intercostalis intimus).
2. Intercostal nerves.
3. Intercostal arteries.
4. Intercostal veins.
5. Intercostal lymph vessels and lymph nodes.
N.B. Plane of neurovascular bundle in the intercostal space:
The neurovascular bundle consisting of intercostal nerve
and vessels lies between the internal intercostal and
innermost intercostal muscles, i.e., between the intermediate
and deepest layers of muscles.
They are arranged in the following order from above
downwards:
1. Intercostal Vein.
2. Intercostal Artery.
3. Intercostal Nerve.
Posterior/
dorsal root
ganglion
Posterior
root
Posterior
primary
ramus
Anterior
primary ramus
(Intercostal
nerve)
Spinal
cord
GR
WR
Anterior root
Lateral
cutaneous
branch
Sympathetic
ganglion
Nerve trunk
Anterior
cutaneous branch
Fig. 16.5 Typical thoracic spinal nerve (GR = grey rami

communicantes, WR = white rami communicantes).
(Mnemonic: VAN)
INTERCOSTAL MUSCLES
Intercostal muscles are a group of muscles that are present in
the intercostal space and help form and move the chest wall.
The following muscles constitute intercostal muscles:
1. External intercostal muscle.
2. Internal intercostal muscle.
3. Innermost intercostal muscle (intercostalis intimi).
N.B. Strictly speaking, the intercostalis intimi is not present
in the intercostal space as it lies on the deeper aspects of
the ribs.
Nerve supply: By intercostal nerves.
Actions
The actions of intercostal muscles are as follows:
1. They act as strong supports for the rib preventing their
separation.
2. They act as elevators of the ribs during respiration.
External intercostal muscles act during inspiration,
while others act during expiration.
The anterior primary rami of upper 11 thoracic spinal

nerves (T1T11) are called intercostal nerves as they course
through the intercostal spaces. The anterior primary ramus
of the 12th thoracic spinal nerve runs in the abdominal wall
below the 12th rib, hence it is called subcostal nerve.
N.B. Unique features: The intercostal nerves are anterior
primary rami of thoracic spinal nerves. They are segmental
in character unlike the anterior primary rami from other
regions of spinal cord which form nerve plexuses viz.
cervical, brachial, lumbar and sacral.
Classification
The intercostal nerves are classified into the following two
groups:
1. Typical intercostal nerves (3rd, 4th, 5th, and 6th).
2. Atypical intercostal nerves (1st, 2nd, 7th, 8th, 9th, 10th,
and 11th).
The typical intercostal nerves are those which remain
confined to their own intercostal spaces.
The atypical spinal nerves extend beyond the thoracic
wall and partly or entirely supply the other regions.
The intercostal muscles are described in detail on page 213214.
TYPICAL INTERCOSTAL NERVE
INTERCOSTAL NERVES
The 12 pairs of thoracic spinal nerves supply the thoracic
wall. As soon as they leave, the intervertebral foramina they
divide into anterior and posterior rami (Fig. 16.5).
Course and Relations

The typical intercostal nerve after its origin turns laterally
behind the sympathetic trunk, and then enters the intercostal
space between the parietal pleura and posterior intercostal
membrane. It then enters the costal groove of the

corresponding rib to course laterally and forwards.
In costal groove it comes into relation with corresponding
intercostal vessels and forms neurovascular bundle of the
intercostal space.
In the intercostal space, vein, artery and nerve lie in that
order from above downwards.
Near the sternal end of the intercostal space, the intercostal
nerve crosses in front of the internal thoracic artery. Then it
pierces internal intercostal muscle, anterior intercostal
membrane, and pectoralis major muscle to terminate as
anterior cutaneous nerve.
N.B.
In the posterior part of intercostal space, the intercostal
nerve lies between the pleura and posterior intercostal
membrane.
In the remaining greater part of intercostal space, it lies
between the internal intercostal and intercostalis intimus
muscles.
Branches
1. Rami communicantes: Each nerve communicates with
the corresponding thoracic ganglion by white and grey
rami communicantes.
2. Muscular branches: These are small tender branches
from the nerve, which supply intercostal muscles and
serratus posterior and superior.
3. Collateral branch: It arises in the posterior part of the
intercostal space near the angle of the rib and runs in the
lower part of the space along the upper border of the rib
below in the same neurovascular plane. It supplies
intercostal muscles, parietal pleura, and periosteum of
the rib.
4. Lateral cutaneous branch: It arises in the posterior
part of the intercostal space near the angle of the rib
and accompanies the main nerve for some distance,
then pierces the muscles of the lateral thoracic wall
along the midaxillary line. It divides into anterior and
posterior branches to supply the skin on the lateral
thoracic wall.
5. Anterior cutaneous branch: It is the terminal branch of
the nerve, which emerges on the side of the sternum. It
divides into medial and lateral branches and supplies the
skin on the front of the thoracic wall.
nerve is very small and it lacks both lateral and anterior

cutaneous branches.
2. Second intercostal nerve: Its lateral cutaneous branch is
called intercostobrachial nerve. It courses across the
axilla and joins the medial cutaneous branch of the arm.
The intercostobrachial nerve supplies the skin of the
floor of the axilla and upper part of the medial side of
the arm. In coronary arterial disease, the cardiac pain is
referred along this nerve to the medial side of the arm.
3. Seventh to eleventh intercostal nerves: These nerves
leave the corresponding intercostal spaces to enter into
the abdominal wall; hence they are called thoracoabdominal nerves. These nerves supply intercostal
muscles of the corresponding intercostal spaces. In
addition they supply:
(a) muscles of anterior abdominal wall, e.g., external
oblique, internal oblique, transverse abdominis, and
rectus abdominis muscles, and
(b) skin and parietal peritoneum covering the outer and
inner surfaces of the abdominal wall, respectively.
Root pain/girdle pain: Irritation of intercostal nerves
caused by the diseases of thoracic vertebrae produces
severe pain which is referred around the trunk along the
cutaneous distribution of the affected nerve. It is termed
root pain or girdle pain.
Sites of eruption of cold abscess on the body wall: Pus
from the tuberculous thoracic vertebra/vertebrae (Potts
disease) tends to track along the neurovascular plane of
the space and may point at three sites of emergence of
cutaneous branches of the thoracic spinal nerve, viz.
(a) just lateral to the sternum, (b) in the midaxillary line, and
(c) lateral to the erector spinae muscle (Fig. 16.6).
Herpes zoster: In herpes zoster (shingles) involving the
thoracic spinal ganglia, the cutaneous vesicles appear in
the dermatomal area of distribution of intercostal nerve. It
is an extremely painful condition.
Intercostal nerve block is given to produce local
anesthesia in one or more intercostal spaces by injecting
the anesthetic agent around the nerve trunk near its
origin, i.e., just lateral to the vertebra.
Thoracotomy: The conventional thoracotomy (posterolateral) is performed along the 6th rib. The neurovascular
bundle is protected from injury by lifting the periosteum of
the rib.
Considering the position of neurovascular bundle in the
intercostal space, it is safe to insert the needle, a little
above the upper border of the rib below.
ATYPICAL INTERCOSTAL NERVES

The atypical intercostal nerves are as follows:
1. First intercostal nerve: The greater part of this nerve
joins the ventral ramus C8 spinal nerve to form lower
trunk of the brachial plexus. The remaining part of the
INTERCOSTAL ARTERIES
The thoracic wall has rich blood supply. It is provided by the
posterior and anterior intercostal arteries.
217
218
Lateral to erector
spinae
Posterior primary ramus
Internal intercostal
External intercostal
In the midaxillary line
Innermost
intercostal
Lateral
cutaneous
branch
Anterior primary ramus

Transversus thoracis
Anterior cutaneous
branch
Sternum
Lateral to sternum
Fig. 16.6 Sites of eruption of tuberculous cold abscess on the body wall. (Source: Fig. 3.1, Page 104, Clinical and Surgical
Anatomy, 2e, Vishram Singh. Copyright Elsevier 2007 All rights reserved.)
Each intercostal space contains one posterior and two

anterior intercostal arteries (upper and lower).
POSTERIOR INTERCOSTAL ARTERIES (Fig. 16.7)

There are 11 pairs of intercostal arteries, one in each space.
They supply the greater part of the intercostal spaces.
Origin
1. The 1st and 2nd posterior intercostal arteries are the
branches of superior intercostal arterya branch of the
costocervical trunk.
2. The 3rd11th posterior intercostal arteries arise directly
from the descending thoracic aorta (Fig. 16.7A).
Course and Relations

In front of the vertebral column (Fig. 16.7B)
The right posterior intercostal arteries are longer than

the left because the descending aorta lies on the left side
of the front of the vertebral column. They pass behind
the esophagus, thoracic duct, azygos vein, and
sympathetic chain but in front of the anterior aspect of
vertebral body.
The left posterior intercostal arteries are smaller and pass
behind the hemiazygos vein and sympathetic chain, but in
front of the side of the vertebral body
In the intercostal space

In the intercostal space, the posterior intercostal artery lies
between the intercostal vein above and the intercostal nerve
below. The neurovascular bundle in the intercostal space lies
between the internal intercostal and intercostalis intimus
muscles.
Termination
Each posterior intercostal artery ends at the level of
costochondral junction by anastomosing with the upper
anterior intercostal artery of the space.
Branches
1. Dorsal branch: It supplies the spinal cord, vertebra and
muscles, and skin of the back.
2. Collateral branch: It arises near the angle of the rib and
runs forwards along the upper border of the rib below
and ends by anastomosing with the lower anterior
intercostal artery.
3. Muscular branches: They supply intercostal, pectoral,
and serratus anterior muscles.
4. Lateral cutaneous branch: It closely follows the lateral
cutaneous branch of the intercostal nerve.
5. Mammary branches (external mammary arteries):
They arise from posterior intercostals arteries of the
2nd, 3rd, and 4th intercostal spaces and supply the breast
mammary gland.
6. Right bronchial artery: It arises from right 3rd posterior
intercostal artery.
Paracentesis thoracis: During paracentesis thoracis
(aspiration of fluid from pleural cavity), the needle should
never be inserted medial to the angle of the rib to avoid
injury to the posterior intercostal artery, as it crosses the
space obliquely from below upwards (for details see page
216).
Coarctation of aorta: In coarctation of aorta (narrowing
of arch of aorta), the posterior intercostal arteries are
markedly enlarged and cause notching of the ribs,
particularly in their posterior parts.

Deep cervical artery
Superior intercostal
arteries
Costocervical trunk
Costocervical trunk
Right subclavian artery

1
1
2
3
5
10
10
11
11
Subcostal
artery
Subcostal
artery
Diaphragm
Right posterior
intercostal artery
Dorsal branch
Left posterior
intercostal artery
Collateral branch
SC
HAV
Thoracic
aorta
AV
TD
Lateral
cutaneous branch
Esophagus
Anterior intercostal
arteries
Internal thoracic artery

Sternum
Fig. 16.7 Posterior intercostal arteries: A, origin; B, course and relations (SC = sympathetic chain, AV = azygos vein, TD =
thoracic duct, HAV = hemiazygos vein).
219
220
ANTERIOR INTERCOSTAL ARTERIES

There are two intercostal arteries in each intercostal space.
They are present in the upper nine intercostal spaces only.
Origin
1. In 1st6th spaces they arise from the internal thoracic
artery.
2. In 7th and 9th spaces, they arise from musculophrenic
artery.
N.B. The 10th and 11th intercostal spaces do not extend
forward enough to have anterior intercostal arteries.
Termination
The anterior intercostal arteries are short and end at the level
of costochondral junction as follows:
1. Upper anterior intercostal artery anastomoses with
corresponding posterior intercostal artery.
2. Lower anterior intercostal artery anastomoses with
collateral branch of the corresponding posterior
intercostal artery.
INTERCOSTAL VEINS
The number of intercostal vein corresponds to the number
of intercostal arteries, i.e., each intercostal space contains
two anterior intercostal veins and one posterior intercostal
vein. Their tributaries correspond to the branches of the
arteries.
ANTERIOR INTERCOSTAL VEINS

1. They are present only in the upper nine spaces.
2. Each space contains two veins and accompanies the
anterior intercostal arteries.
Termination
1. In upper six spaces, they end in the internal thoracic
vein.
2. In seventh, eighth, and ninth spaces, they end in the
musculophrenic vein.
POSTERIOR INTERCOSTAL VEINS

1.
2.
3.
4.
They are present in all the spaces.

Each space contains only one posterior intercostal vein.
Each vein accompanies the posterior intercostal artery.
Its tributaries correspond to the branches of posterior
intercostal artery.
Termination (Fig. 16.8)

The mode of drainage (termination) of posterior intercostal
veins differs on the right and left sides (Table 16.2).
INTERCOSTAL LYMPH VESSELS AND

LYMPH NODES
LYMPH VESSELS
1. The lymph vessels from the anterior parts of the spaces
drain into anterior intercostal/internal mammary lymph
nodes. The efferent from these nodes unite with those of
tracheobronchial and brachiocephalic nodes to form the
bronchomediastinal trunk, which drains into subclavian
trunk on the right side and thoracic duct on the left side.
2. The lymph vessels from the posterior parts of the spaces
drain into posterior intercostal nodes. The efferent from
the posterior intercostal nodes of lower four spaces unite
to form a slender lymph trunk, which descends and
drain into the cysterna chyli. The efferent from posterior
intercostal nodes of upper spaces drain into right
lymphatic duct on the right side and thoracic duct on
the left side.
LYMPH NODES
1. Posterior intercostal nodes.
2. Anterior intercostal/internal mammary (parasternal)
nodes.
The posterior intercostal nodes are located in the posterior
part of the intercostal spaces on the necks of the ribs.
The anterior intercostal nodes lie along the course of
internal thoracic (mammary) artery.
INTERNAL THORACIC ARTERY (Fig. 16.9)

There are two internal thoracic arteries, right and left,
situated deep to anterior chest wall, one on either side of
sternum.
Origin
The internal thoracic artery arises from the first part of the
subclavian artery (lower surface), about 2.5 cm above the
medial end of the clavicle, opposite the origin of the
thyrocervical trunk.
Course and Termination
The internal thoracic artery descends behind the medial end
of the clavicle and upper six coastal cartilages, about 1 cm
away from the lateral margin of the sternum. It ends in the
6th intercostal space by dividing into superior epigastric and
musculophrenic arteries.

Left superior intercostal vein
Superior
vena cava
3
4
Right superior
intercostal vein
6
Accessory hemiazygos vein
Azygos vein
8
8
9
10
10
11
11
Hemiazygos vein
Subcostal vein
Subcostal vein
Left ascending lumbar vein
Right ascending lumbar vein
IVC
Left renal vein

Right renal vein
Fig. 16.8 Drainage of posterior intercostal veins. Note that posterior intercostal veins are numbered 111 from above
downwards.
Table 16.2 Mode of termination of right and left posterior intercostal veins
Right posterior intercostal veins
Left posterior intercostal veins
1st (highest) drains into the right brachiocephalic vein
1st (highest) drains into left brachiocephalic vein
2nd, 3rd, and 4th join to form right superior intercostal

vein, which in turn drains into the azygos vein
2nd, 3rd, and 4th join to form left superior intercostal vein, which
in turn drains into left brachiocephalic vein
5th11th drain into the azygos vein
5th8th drain into accessory azygos vein

9th11th drain into hemiazygos vein
Subcostal vein drains into the azygos vein
Relations
Subcostal vein drains into the hemiazygos vein
Anteriorly: From above downwards, it is related to:

Medial end of the clavicle.

Internal jugular vein.
Brachiocephalic vein.

Phrenic nerve.
Pectoralis major.
Upper six costal cartilages.
External intercostal membranes.
Internal intercostal muscles.
Upper six intercostal nerves.
221
222
Thyrocervical trunk
Scalenus
anterior muscle
Vertebral artery
Subclavian artery
Internal
thoracic artery
6th ICS
Superior epigastric artery

Musculophrenic artery
Fig. 16.9 Origin, course, and termination of internal thoracic

artery (ICS = intercostal space).
Posteriorly:

4. Perforating branches: They accompany the anterior

cutaneous branches of intercostal nerves. In females, the
perforating branches of 2nd, 3rd, and 4th intercostal
spaces are quite large and supply the breast.
5. Superior epigastric artery: It runs downwards behind
the 7th costal cartilage between the sternal and 1st costal
slips of diaphragm to enter the rectus sheath where it
ends by anastomosing with the inferior epigastric artery.
It supplies anterior body wall from clavicle to the
umbilicus.
6. Musculophrenic artery: It runs downwards and
laterally behind the 7th, 8th, and 9th costal cartilages,
and gives two anterior intercostal arteries to each of the
7th, 8th, and 9th intercostal spaces. It pierces the
diaphragm near the 9th costal cartilage, to reach under
surface. It supplies diaphragm and muscles of the
anterior abdominal wall.
Above the 2nd costal cartilage, it is related to

endothoracic fascia and pleura.
Below the 2nd costal cartilage, it is related to
sternocostalis muscle, which intervenes between
the artery and the endothoracic fascia and pleura.
N.B. The internal mammary artery is accompanied by two

venae comitantes, which unite at the level of 3rd costal
cartilage to form the internal thoracic (mammary) vein, which
runs upwards along the medial side of the artery to terminate
into the brachiocephalic vein at the root of the neck.
Branches
1. Pericardiophrenic artery: It arises in the root of the neck
above the 1st costal cartilage, and descends along with
phrenic nerve to the diaphragm. It supplies pericardium
and pleura.
2. Mediastinal branches: They are small inconstant twigs,
which supply connective tissue, thymus, and front of the
pericardium.
3. Anterior intercostal arteries: They are two for each of
the upper six intercostal spaces.
Role of internal mammary artery in treatment of

coronary heart diseases:
The internal thoracic artery is sometimes used to treat
coronary heart disease. When the segment of coronary
artery is blocked by atherosclerosis, (mostly), the diseased
arterial segment is bypassed by inserting a graft. The graft
most commonly used is taken from great saphenous vein
of the leg. In some patients, the myocardium is
revascularized by mobilizing the internal thoracic artery
and joining its distal cut end to the coronary artery distal to
the diseased segment.
The internal mammary artery graft (IMA graft) is
preferred over grafts from other vessels, because IMA
graft lasts long. Recently it has been found that internal
mammary arteries are less prone to develop
atherosclerosis because of their histological peculiarity.
The walls of these arteries contain only elastic tissue and
the cells of their endothelial lining secrete some chemicals,
which prevents atherosclerosis. The left internal mammary
artery is preferred over right internal mammary artery,
because it is easier to access it.
Earlier the internal thoracic artery was used to be ligated
in the 3rd intercostal space in order to reinforce the blood
supply to the heart by diverting blood from this artery to
its pericardiophrenic branch. This procedure is now
obsolete.
MECHANISM OF RESPIRATION
The respiration consists of two alternate phases of
(a) inspiration and (b) expiration, which are associated
with alternate increase and decrease in the volume of
thoracic cavity, respectively. During inspiration, the air is
taken in (inhaled) and during expiration, the air is taken
out (exhaled).
224
Fig. 16.13 Increase in transverse diameter of the thoracic cavity due to bucket-handle movements of vertebrochondral rib:
A, idealized representation; B, actual movements of the ribs.
the ribs move outwards like the bucket handlebucket

handle movement. This causes increase in the transverse
diameter of the thoracic cavity (Fig. 16.13). The axis of
movement passes from the tubercle of this rib to the middle
of the sternum.
The bucket-handle movement is produced by
vertebrochondral ribs.
The main factors responsible for increase in various
diameters of the thoracic cavity are summarized in Table
16.3.
Table 16.3 Factors responsible for the increase in various

diameters of the thoracic cavity during inspiration
Diameter
Factors responsible for increase
Vertical
Descent (contraction) of the diaphragm
Anteroposterior
Pump-handle movement of the sternum

(brought about by the elevation of
vertebrosternal ribs)
Transverse
Bucket-handle movement of the

vertebrochondral ribs
Table 16.4 Muscles acting during different types of respiration

Type of respiration
Inspiration (elevation of ribs)
Expiration (depression of ribs)
Quiet respiration
External intercostal muscles
Passive
Diaphragm
No muscles
Passive
Scalene muscles
No muscles
Deep respiration
Sternocleidomastoid
Levatores costarum
Serratus posterior superior
Diaphragm
Forced respiration
All the muscles involved in deep inspiration
(vide supra)
Levator scapulae
Trapezius
Rhomboids
Pectoral muscles
Serratus anterior
Quadratus lumborum
Internal intercostal muscles
Transverse thoracis
Serratus posterior inferior
EXPIRATION
The expiration is the passive process brought about by
(a) elastic recoil of the alveoli of the lungs,
(b) relaxation of the intercostal muscles and the diaphragm,
and
(c) increase in the tone of the muscles of anterior abdominal
wall.
In forced respiration, all movements are exaggerated.

The scapula is fixed and elevated by trapezius, levator
scapulae, rhomboideus major, and rhomboideus minor
muscles, so that pectoral muscles and serratus anterior
can raise the ribs.
The muscles acting during different types of
respiration (i.e., respiratory muscles) are enumerated in
Table 16.4.
TYPES OF RESPIRATION (BREATHING)

The respiration is classified into the following three types:
1. Quiet respiration.
2. Deep respiration.
3. Forced respiration.
In quiet respiration, the movements are normal as
described above.
In deep respiration, movements described for quiet
respiration are increased. The 1st rib is elevated by scalene
and sternocleidomastoid muscles.
Posture of patient during asthmatic attack: During
asthmatic attack (characterized by breathlessness/
difficulty in breathing), the patient is most comfortable on
sitting up, leaning forwards and fixing the arms on the
bed/table. This is because in the sitting position, the
diaphragm is at its lowest level, allowing maximum
ventilation. Fixation of arms fixes the scapulae, so that
the pectoral muscles and serratus anterior may act on the
ribs which they elevate.
225
CHAPTER
17
Pleural Cavities
The thoracic cavity is divided into three compartments (Fig.

17.1): right and left lateral compartments and middle
compartment. Each lateral compartment is occupied by a
Middle compartment
lung enclosed in the serous sac called pleural cavity. The

middle compartment contains, essentially, all the thoracic
structures except lungs, such as heart with its pericardium,
great blood vessels that leave or enter the heart, structures
that traverse the thorax to enter the abdomen in passing from
the neck to the abdomen or from abdomen to neck such as
esophagus, vagus nerves, phrenic nerves, and thoracic duct.
The mass of tissues and organs occupying the middle
compartment form a mobile septummediastinum that
completely separates the two pleural cavities.
PLEURAL CAVITIES (Fig. 17.2)
Right lateral compartment

(right pleural/pulmonary cavity)
Left lateral compartment

(left pleural/pulmonary cavity)
A
Mediastinum
Pleural cavity
Root of lung
Parietal pleura
Visceral pleura
Lung
Lung
Thoracic wall
Fig. 17.1 Compartment of the thoracic cavity: A, empty

compartments; B, lateral compartments occupied by lung
enclosed in the serous sac (pleural sac).
Each lung is invested by and enclosed in a serous sac which

consists of two continuous serous membranesthe visceral
pleura and parietal pleura. The visceral pleura invests all the
surfaces of the lung forming its shiny outer surface, whereas
the parietal pleura lines the pulmonary cavity (i.e., thoracic
wall and mediastinum).
The space between the visceral and parietal pleura is
called pleural cavity.
A little description of development of lung makes it is
easier to understand the relationship of the lung and pleura.
During early embryonic life, each lateral compartment of
the thoracic cavity is occupied by a closed serous sac, which
is invaginated from the medial side by the developing lung
and as a result of this invagination, it converted into a
double-layered sac. The outer layer is called parietal pleura
and the inner layer is called visceral pleura. The visceral
pleura is continuous with parietal pleura at the root of the
lung. The parietal and visceral layers are separated from each
other by a slit-like potential space called pleural cavity. The
pleural cavity is normally filled with a thin film of tissue
fluid, which lubricates the adjoining surfaces of the pleura
and allows them to move on each other without friction.
The two layers become continuous with each other by
means of a cuff of pleura, which surrounds the root of the
lung consisting of structures entering and leaving the lung at
the hilum of the lung, such as principal bronchi and
228
Laryngotracheal
tube
root of the lung as far down as the diaphragm between the

lung and the mediastinum.
Lung bud
Pleural sac
PLEURA
The pleura-like peritoneum is a serous membrane lined by
flattened epithelium (mesothelium). The lining epithelium
secretes a watery lubricantthe serous fluid.
LAYERS OF THE PLEURA
Parietal pleura
Visceral pleura
Root of lung
The pleura consist of two layers: (a) visceral pleura and

(b) parietal pleura. The moistened space between the two
layers is called pleural cavity (vide supra).
Visceral Pleura (Pulmonary Pleura)

The visceral pleura completely covers the surface of the lung
except at the hilum and along the attachment of the
pulmonary ligament. It also extends into the depths of the
fissures of the lungs. It is firmly adherent to the lung surface
and cannot be separated from it.
Parietal Pleura
The parietal pleura is thicker than the visceral pleura and
lines the walls of the pulmonary cavity.
Subdivisions
For the purpose of description, it is customary to divide
parietal pleura, according to the surface, which it lines, covers
or the region in which it lies. Thus parietal pleura is divided
into the following four parts (Fig. 17.3):
1.
2.
3.
4.
Costal pleura.
Diaphragmatic pleura.
Mediastinal pleura.
Cervical pleura.
Parietal pleura
Pleural cavity
LUNG
LUNG
Visceral pleura
Costal pleura: It lines the inner surface of the thoracic wall

(consisting of ribs, costal cartilages, and intercostal spaces)
to which it is loosely attached by a thin layer of loose areolar
tissue called endothoracic fascia. In living beings,
endothoracic fascia is easily separable from the thoracic wall.
Diaphragmatic pleura: It covers the superior surface of the
diaphragm. In quiet respiration, the costal and diaphragmatic
pleura are in opposition to each other below the inferior
border of the lung.
Fig. 17.2 Invagination of developing lungs into the closed

serous sacs.
pulmonary vessels. To allow the movement of principal

bronchi and pulmonary vessels during respiration, the cuff
of pleura hangs down as loose triangular fold called
pulmonary ligament. The pulmonary ligament extends from
Mediastinal pleura: It lines the corresponding surface of the

mediastinum and forms its lateral boundary. It is reflected as
a cuff over the root of the lung and becomes continuous with
the visceral pleura.
Cervical pleura: It is the dome of parietal pleura, which
extends into the root of the neck about 1 inch (2.5 cm) above
the medial end of clavicle and 2 inches (5 cm) above the 1st
230
SURFACE MARKINGS OF THE PLEURA (Fig. 17.5)

The knowledge of reflexion of parietal pleura on the surface
of the chest wall is of great importance while carrying out
various medical and surgical procedures.
The reflection of parietal pleura can be marked on the
surface by the following lines:
1. Cervical pleura: It is marked by a curved line (with
convexity directed upwards) drawn from sternoclavicular
joint to the junction of medial third and middle third of
the clavicle. The summit of dome of pleura lies 1 inch
(2.5) above the medial one-third of the clavicle.
2. Anterior (costomediastinal) line of pleural reflection: It
differs on the two sides:
(a) On the right side, it extends downwards and
medially from the right sternoclavicular joint to the
midpoint of the sternal angle, and then descends
vertically up to the midpoint of the xiphisternal
joint.
(b) On the left side, it extends downwards and medially
from the left sternoclavicular joint to the midpoint
of the sternal angle, then descends vertically only up
to the level of the 4th costal cartilage. It then arches
outwards to reach the sternal margin of sternum

and runs downwards a short distance lateral to this
margin to reach the 6th costal cartilage, about 3 cm
from the midline leaving a part of pericardium
directly in contact with anterior chest wall (bare
area of the heart).
3. Inferior (costodiaphragmatic) line of pleural reflection:
It passes laterally around the chest wall from the lower
limit of the anterior line of pleural reflection. It differs
slightly on two sides:
(a) On the right side, the line of reflection starts from
the xiphisternal joint or behind the xiphoid process
and crosses the 8th rib in the midclavicular line,
10th rib in the midaxillary line, and 12th rib at the
lateral border of the erector spinae muscle, 2 cm
lateral to the spine of T12 vertebra.
(b) On the left side, the line of reflection starts at the
level of the 6th costal cartilage, about 2 cm lateral to
the midline. Thereafter it follows the same course as
on the right side.
4. Posterior (costovertebral) line of pleural reflection: It
ascends from the end of the inferior line, 2 cm lateral to
the T12 spine along the vertebral column to the point,
2.5 cm above the medial
3rd of the clavicle
Junction of medial and middle
3rd of the clavicle
Midpoint of sternal angle
Level of 4th costal cartilage
C4
6th costal cartilage
Midpoint of
xiphisternal angle
8th rib in the
midclavicular line
R12
T12
8th rib in the midclavicular line
10th rib in the midaxillary line
10th rib in the

midaxillary line
Posterior end 2 cm from midline

at the level of T12 spine
Fig. 17.5 Schematic diagram showing lines of pleural reflection.
12th rib at the lateral border

of erector spinae muscle
Pleural Cavities
2 cm lateral to the spine of C7 vertebra. The costal pleura

becomes mediastinal pleura along this line.
N.B. The inferior margin of the lung passes more horizontally
than the inferior margin of the pleura. Consequently, it
crosses the 6th rib in the midclavicular line, 8th rib in the
midaxillary line, and 10th rib at the lateral border of the
erector spine.
The ribs crossed by inferior margin of the lung and pleura
in midclavicular line, midaxillary line, and lateral to erector
spine are compared below:
Inferior margin of lung: 6th rib, 8th rib, and 10th rib
Inferior margin of pleura: 8th rib, 10th rib, and 12th rib
notch in the left lung. Its location can be confirmed clinically

by percussion (tapping) of the chest wall. As one moves
during tapping from the area of underlying lung tissue to the
area of left costomediastinal recess unoccupied by lung
tissue, a change in tone, from resonant to dull, is noticed.
This is called the area of superficial cardiac dullness.
Radiological appearance of pleural effusion: When a
small quantity of fluid collects in the costodiaphragmatic

recess (pleural effusion) the costodiaphragmatic angle is
obliterated (widening of the angle). It is seen as
radiopaque shadow with a fluid line in X-ray chest. This
may be the first indication of pleural effusion. Therefore
recesses of pleura are examined routinely in the chest
radiographs.
The costodiaphragmatic recess can be entered through
the 9th and 10th intercostal spaces without penetrating
the lung in patient with quiet breathing because it lies
opposite 8th10th ribs.
Sites of extension of pleura beyond the thoracic cage:
There are five sites, where pleura extends beyond the
thoracic cage.
These sites are as follows:
1. On either side in the root of the neck (as domes of
pleura).
2. In the right xiphisternal angle.
3. On either side in the costovertebral angle.
The pleura can be punctured inadvertently at these sites
during surgical procedures.
RECESSES OF THE PLEURA (Fig. 17.3)

Normally the space between the parietal and visceral pleura
is only a potential space and is filled with thin film of serous
fluid. However in areas of pleural reflection on to the
diaphragm and mediastinum, the space between the parietal
and visceral pleura is greatly expanded. These expanded
regions of pleural cavity are called pleural recesses. They are
essential for lung expansion during deep inspiration. Thus
pleural recesses serve as reserve spaces of pleural cavity for the
lungs to expand during deep inspiration. The recesses of
pleura are as follows:
1. Costodiaphragmatic recesses (right and left).
2. Costomediastinal recesses (right and left).
N.B. In addition to the above recesses of pleura, there are
three more small recesses, viz.
Right and left retroesophageal recesses
These are formed by the reflection of mediastinal pleura
behind the esophagus. Each recess is thought to be
occupied by a part of the lung, and contributes to the
retrocardiac space seen in the radiographs of the chest.
Infracardiac recess
It is a small recess of right pleural sac which sometimes
extends beneath the inferior vena cava.
Costodiaphragmatic recess (Fig. 17.3A): It is located

inferiorly between the costal and diaphragmatic pleurae.
Vertically it measures about 5 cm and lies opposite the
8th10th ribs along the midaxillary line. The
costodiaphragmatic recesses are the most dependent parts of
the pleural cavities, hence the fluid of pleural effusion first
collect at these sites.
Costomediastinal recess (Fig. 17.3B): It is located anteriorly
between the costal and mediastinal pleurae and lies between
sternum and costal cartilages. The right costomediastinal
recess is possibly occupied by the anterior margin of the
right lung even during quiet breathing. The left
costomediastinal recess is large due to the presence of cardiac
NERVE SUPPLY OF THE PLEURA

The parietal pleura develops from somatopleuric layer of the
lateral plate of mesoderm, hence it is supplied by the somatic
nerves and is sensitive to pain:

Costal and peripheral part of the diaphragmatic pleura is

supplied by the intercostal nerves.
Mediastinal and central part of the diaphragmatic pleura
is supplied by the phrenic nerve.
The visceral pleura develops from splanchnopleuric layer

of the lateral plate of mesoderm, hence it is supplied by the
autonomic (sympathetic) nerves (T2T5) and is insensitive
to pain.
Referred pain of pleura: The pain from central
diaphragmatic pleura and mediastinal pleura is referred to
the neck or shoulder through phrenic nerves (C3, C4, and
C5) because skin at these sites has same segmental supply
through the supraclavicular nerves (C3, C4, and C5).
231
232
BLOOD SUPPLY AND LYMPHATIC

DRAINAGE OF THE PLEURA
Blood supply of parietal pleura is same as that of the
thoracic wall and blood supply of the visceral (pulmonary)
pleura is same as that of the lung.
Table 17.1 enumerates the differences between parietal
and visceral pleura.
Pleurisy or pleuritis: It is the inflammation of the parietal
pleura. Clinically it presents as pain, which is aggravated
by respiratory movements and radiates to thoracic and
abdominal walls. It is commonly caused by pulmonary
tuberculosis. The pleural surface becomes rough due to
accumulation of inflammatory exudate. Due to roughening
of the pleural surfaces friction occurs between the two
layers of pleura during respiratory movements. Thus
pleural rub can be heard with stethoscope on the surface
of the chest wall during inspiration and expiration.
The collection of serous fluid, air, blood, and pus in the
pleural cavity is termed hydrothorax (pleural effusion)
pneumothorax, hemothorax, and pyothorax (empyema),
respectively.
Pleural effusion (Fig. 17.6): Normally the pleural cavity
contains only 510ml of clear fluid, which lubricates the
pleural surfaces to allow their smooth movements without
friction. The excessive accumulation of fluid in the pleural
cavity is called pleural effusion. It usually occurs due to
inflammation of pleura. The pleural effusion leads to
decreased expansion of lung on the side of effusion.
Clinically it can be detected with decreased breath sounds
and dullness on percussion on the site of effusion.
Thoracocentesis/pleural tab: It is a procedure by which
an excess fluid is aspirated from the pleural cavity. It is
performed with the patient in sitting position. Usually the
needle is inserted in the 6th intercostal space in the
midaxillary line. The needle is inserted into the lower part
of the intercostal space along the upper border of the rib
to avoid injury to the intercostal nerve and vessels. The
needle passes in succession through skin, superficial
fascia, serratus anterior, intercostal muscles, endothoracic
fascia, and parietal pleura to reach the pleural cavity.
Pneumothorax (Fig. 17.7): Accumulation of air in the
pleural cavity is called pneumothorax.
Spontaneous pneumothorax: As the name indicates, in
this condition, air enters pleural cavity suddenly due the
rupture of emphysematous bullae of the lung.
Open pneumothorax: This condition occurs due to stab
wounds on the thoracic wall piercing the pleurae,
leading to the communication of air in the pleural cavity
with the outside (atmospheric) air. Consequently, each
time when patient inspires, the air is sucked into the
pleural cavity. Sometimes the clothing and the layers of
thoracic wall combine to form a valve so that air enters
through the wound during inspiration, but cannot exit
through it. In these circumstances, air pressure builds
up continuously in the pleural cavity on the wounded
side which pushes the mediastinum to the opposite
Table 17.1 Differences between the parietal and visceral

pleurae
Parietal pleura
Lines the thoracic wall and
mediastinum
Develops from the
somatopleuric mesoderm
Innervated by the somatic
nerves
Sensitive to pain
Blood supply and
lymphatic drainage is same
as that of thoracic wall
Visceral pleura
Lines the surface of the lung
Develops from the
splanchnopleuric mesoderm
Innervated by the autonomic
nerves
Insensitive to pain
Blood supply and lymphatic
drainage is same as that of the
lung
Diminished
breath sounds
Serous fluid
Fig. 17.6 Pleural effusion.
Partially
collapsed lung
Atmospheric air
Accumulation
of air in the
pleural cavity
Fig. 17.7 Pneumothorax.
(healthy) side. This is called tension pneumothorax. The

tension pneumothorax is characterized by (a) collapse
of lung on the affected side, and (b) compression of
lung on the healthy side.
CHAPTER
18
Lungs (Pulmones)
LUNGS (PULMONES)
The lungs or pulmones are the principal organs of
respiration. The two lungs (right and left) are situated in the
thoracic cavity, one on either side of the mediastinum
enclosed in the pleural sac. The main function of lungs is to
oxygenate the blood, i.e., exchange of O2 and CO2 between
inspired air and blood. Each lung is large conical/pyramidal
shaped with its base resting on the diaphragm and its apex
extending into the root of the neck. The right lung is larger
and heavier than the left lung. The right lung weighs about
700 g and left lung 650 g. The right lung has three lobes and
the left lung has two lobes. The lobes are separated by deep
prominent fissures on the surface of the lung and are
supplied by two lobar bronchi (Fig. 18.1).
The lungs are attached to the trachea and heart by
principal bronchi and pulmonary vessels, respectively.
In newborn baby and people living in clean environment,

the lungs are rosy pink in color, but in people living in
polluted areas or those who are smokers, have the lungs are
brown or black in color, and mottled in appearance due to
inhaled carbon particles.
In the adults, the lungs are spongy in texture and
crepitate on touch due to the presence of air in their alveoli.
They float in water. In fetus and stillborn children, the
lungs are solid and do not crepitate on touch due to the
absence of air in their alveoli. They sink in water.
EXTERNAL FEATURES
Each lung presents the following features (Figs 18.1 and
18.2):
1. Apex.
2. Base.
Trachea
Apex
Posterior border
Horizontal fissure
Oblique fissure
Oblique fissure
Cardiac notch
Lingula
Inferior border
Base
Anterior border
Fig. 18.1 Trachea and lungs as seen from the front.
Lungs (Pulmones)
Apex
Medial surface
Left superior
lobar bronchus
Right upper
lobar bronchus
Costal surface
Horizontal fissure
Left inferior
lobar bronchus
Right middle
lobar bronchus
Oblique fissure
Oblique fissure
Lingula
Base
Right inferior lobar
bronchus
Cardiac notch
Fig. 18.2 Lobes of the lung with lobar bronchi.
3. Three borders (anterior, posterior, and inferior).

4. Two surfaces (costal and medial).
Anatomical position and side determination
The side of lung can be determined by holding the lung in
such a way that:
(a) its conical end (apex) is directed upwards and its broader
end (base) is directed downwards,
(b) its convex surface (costal surface) is directed outwards
and its flat medial surface presenting hilum is directed
inwards,
(c) its thin margin (anterior margin) should face forwards
and its rounded border (posterior border) should face
backwards.
N.B. The side should not be determined by number of
fissures and lobes as they are variable.
The external features are discussed in detail in the following

text.
APEX
The apex is rounded/blunt superior end of the lung. It
extends into the root of the neck about 3 cm superior to the
anterior end of the 1st rib and 2.5 cm above the medial onethird of the clavicle. It is covered by cervical pleura and
suprapleural membrane.
Relations
Anterior: (a) Subclavian artery, (b) internal thoracic artery,
and (c) scalenus anterior.
Posterior: Neck of 1st rib and structures in front of it, e.g., (a)
ventral ramus of first thoracic nerve, (b) first
posterior intercostal artery, (c) first posterior
intercostal vein, and (d) sympathetic chain.
N.B.
All the structures related to the apex are separated from
it by suprapleural membrane.
Apex is grooved by subclavian artery on the medial side
and on the front.
Pancoast syndrome: It occurs due to involvement of
structures related to the posterior aspect of the apex of lung
by the cancer of the lung apex.
Clinical features
Pain along the medial side of forearm and hand, and
wasting of small muscles of the hand due to involvement
of ventral ramus of T1.
Horners syndrome, due to involvement of sympathetic
chain.
Erosion of first rib.
N.B. Cancer of lung apex may spread to involve neighboring

structures, such as subclavian or brachiocephalic vein,
subclavian artery, phrenic nerve causing following signs and
symptoms.
Venous engorgement and edema in neck, face, and arm
due involvement of subclavian and brachiocephalic
veins.
Diminished brachial and/or radial pulse due to
compression on subclavian artery.
Paralysis of hemidiaphragm due to infiltration of phrenic
nerve.
BASE
The base is lower semilunar concave surface, which rests on
the dome of the diaphragm, hence it is also sometimes called
diaphragmatic surface.
235
236
Relations
On the right side, the lung is separated from the liver by the
right dome of the diaphragm, and on the left side, the left
lung is separated from the spleen and fundus of stomach by
the left dome of the diaphragm.
N.B. The base of the right lung is deeper (i.e., more
concave) because right dome of diaphragm rises to the
more superior level due to the presence of liver underneath
it.
BORDERS
The borders of the lungs are as follows:
1. Anterior border: It is thin and shorter than the posterior
border. The anterior border of right lung is vertical. The
anterior border of left lung presents a wide cardiac
notch, which is occupied by the heart and pericardium.
In this region, the heart and pericardium is uncovered
by the lung. Hence this region is responsible for an area
of superficial cardiac dullness. Below the cardiac notch,
it presents a tongue-shaped projection called lingula.
2. Posterior border: It is thick and rounded. It extends
from spine of C7 vertebra to the spine of T10 vertebra.
3. Inferior border: It is semilunar in shape and separates
the costal and medial surfaces.
SURFACES
The surfaces of the lungs are costal and medial.
Costal Surface
It is large, smooth, and convex. It is covered by the costal
pleura and endothoracic fascia.
Relations
It is related to the lateral thoracic wall. (In embalmed and
hardened lung, the costal surface presents impressions of the
ribs.)
The number of ribs related to this surface is as follows:

Upper 6 ribs in midclavicular line.

Upper 8 ribs in midaxillary line.
Upper 10 ribs in scapular line.
Medial Surface
It is divided into two parts (a) small posterior vertebral part,
and (b) large anterior mediastinal part.
Relations
The vertebral part is related to the vertebral column,
posterior intercostal vessels, and greater and lesser splanchnic
nerves.
The mediastinal part presents a hilum, and it is related to

mediastinal structures such as heart, great blood vessels, and
nerves. Since the right and left surfaces of mediastinum
consists of different structures. The relations of the
mediastinal surface of the two lungs differ because structures
forming right and left surfaces of mediastinum differ. To
understand the relations of the mediastinal surfaces of the
lungs, the students are advised to know the structures
forming the right and left surfaces of the mediastinum.
Structures forming
(Fig. 19.3A):
right
surface
of
mediastinum
1. The right mediastinal surface mainly consists of right

atrium.
2. Above the right atrium are present superior vena cava
and right brachiocephalic vein.
3. Behind these structures are present the trachea and
esophagus.
4. The azygos vein, a large venous channel, runs upwards
along the side of vertebral column and arches over the
root of the right lung to terminate into the superior vena
cava.
5. Three neural structures, viz. (a) right phrenic nerve,
(b) right vagus nerve, and (c) right sympathetic chain.
The phrenic nerve runs to diaphragm passing

superficial to three venous structures from above
downwards(i) superior vena cava, (ii) right atrium,
and (iii) inferior vena cava. This course is in front of
the root of the lung.
The vagus nerve lies against the right side of the trachea
and travels behind the lung root. Here it breaks up into
branches to take part in the formation of posterior
pulmonary plexus and esophageal plexus.
The sympathetic trunk runs in the paravertebral gutter.
The splanchnic nerves leave its lower half, run medially, and
pierce the crura of diaphragm to reach the abdomen.
Structures forming left surface of the mediastinum
(Fig. 19.3B):
1. The left ventricle and aorta are the main structures
forming the left surface of the mediastinum.
2. Aorta ascends at first, arches over the left lung root, and
then descends behind the lung root.
3. Three greet vessels (brachiocephalic trunk, left common
carotid artery, and left subclavian vein) arise from the
aortic arch and ascend up to reach the root of the neck.
4. The esophagus as it descends through thorax shifts to
the left behind the heart and gently crosses the line of
the descending aorta.
5. Three neural structures, viz. (a) left phrenic nerve,
(b) left vagus nerve, and (c) left sympathetic chain.
Lungs (Pulmones)
Table 18.1 Relations of the mediastinal surfaces of the

right and left lungs
Mediastinal surface of the
right lung
Right atrium
Superior and inferior vena
cavae
Azygos vein
Esophagus and trachea
Three neural structures
Right phrenic nerve
Right vagus nerve
Right sympathetic chain
Groove for right

subclavian artery
Esophagus
Mediastinal surface of the left

lung
Left ventricle
Ascending aorta
Arch of aorta and descending
thoracic aorta
Left subclavian and left
common carotid arteries
Esophagus and thoracic duct
Four neural structures
Left phrenic vein
Left vagus nerve
Left recurrent pharyngeal
nerve
Left sympathetic chain
The left phrenic nerve crosses the aortic (left) side,

passes in front of the lung root, and runs down
superficial to left ventricle to reach the diaphragm.
The left vagus nerve is held away from the trachea by
the aortic arch. Here it gives recurrent laryngeal
branch, which hooks under the aortic arch, ascends
up into the tracheoesophageal groove. Below the
aortic arch, the vagus nerve runs behind the lung root
and breaks up into posterior pulmonary and
esophageal branches.
The position of sympathetic trunk and splanchnic
nerves is similar to those of the right side.
The relations of mediastinal surfaces of right and left

lungs are given in Table 18.1 and shown in Figures 18.3 and
18.4.
The impressions produced by mediastinal structures on
the medial surfaces of lungs are shown in Figures 18.5 and
18.6.
Right vagus
nerve
Trachea
Superior
vena cava
Right phrenic
nerve
Arch of
azygos vein
Root of
right lung
Right atrium
Inferior
vena cava
Fig. 18.3 Structures related to the mediastinal surface of

the right lung.
Esophagus
Trachea
Thoracic
duct
Left vagus
Left recurrent
laryngeal nerve
Left subclavian
artery
Left common
carotid artery
Arch of aorta
Left phrenic
nerve
Root of
left lung
Left ventricle
Cardiac notch
Esophagus
Descending
thoracic aorta
LOBES AND FISSURES (Figs 18.1 and 18.2)

The right lung is divided into three lobes: superior, middle,
and inferior by two fissures(a) an oblique fissure and (b) a
horizontal fissure.
The left lung is divided into two lobes: (a) superior and
(b) inferior by an oblique fissure.
Fig. 18.4 Structures related to the mediastinal surface of

the left lung and producing impression on this surface.
1. Oblique fissure: A long oblique fissure runs obliquely

downwards and forwards crossing the posterior border
about 6 cm (2 inches) below the apex and inferior border
about 7.5 cm (3 inches) lateral to the midline. It separates
the superior and middle lobes from the inferior lobe.
2. Horizontal fissure: A short horizontal fissure is present

only in the right lung. It starts from oblique fissure at the
midaxillary line and runs horizontally forward to the
anterior border of the lung. It separates the superior and
middle lobes.
237
238
Groove for right

subclavian artery
Apex
Groove for superior

vena cava
Oblique fissure
Groove for azygos vein
Superior lobar bronchus
Anterior border
Right pulmonary artery
Upper right
pulmonary vein
Right principal bronchus
Horizontal fissure
Groove for esophagus
Cardiac impression
Lower right pulmonary vein
Oblique fissure
Pulmonary ligament
Base of lung
Groove for inferior vena cava
Fig. 18.5 The impressions produced by mediastinal structures on the medial surface of the right lung. (Source:
Fig. 63.6, Page 1066, Grays Anatomy: The Anatomical Basis of Clinical Practice, 39th ed., Susan Standring (Editor-inChief). Copyright Elsevier Ltd., 2005, All rights reserved.)
Apex
Groove for left

subclavian artery
Groove for left
brachiocephalic vein
Pulmonary artery
Groove for aorta
Left principal
bronchus
Left pulmonary
veins
Posterior border
Pulmonary ligament
Cardiac
impression
Cardiac notch
Lingula
Inferior border
Fig. 18.6 The impressions produced by mediastinal structures on the medial surface of the left lung. (Source: Fig. 63.7,
Page 1067, Grays Anatomy: The Anatomical Basis of Clinical Practice, 39th ed., Susan Standring (Editor-in-Chief).
Elsevier Ltd, 2005, All rights reserved.)
Lungs (Pulmones)
Mesentery of
azygos arch
Pulmonary
pleura
Azygos lobe
Azygos venous
arch
The hilum is the area on the mediastinal surface of the

lung through which structures enter or leave the lung.
The root of lung is surrounded by a tubular sheath derived
from the mediastinal pleura.
COMPONENTS
The root of lung consists of the following structures:
Fig. 18.7 Formation of azygos lobe of the lung.
The oblique fissure in left lung runs obliquely downwards

and forwards crossing the posterior border about 6 cm below
the apex and inferior border almost at its apex. It separates
the superior lobe from the inferior lobe.
N.B.
The oblique fissure acts as a plane of cleavage so that
during inspiration, the upper part of lung expands
forwards and laterally, whereas the lower part of the lung
expands downwards and backwards.
In X-ray chest PA view, the horizontal fissure is visible in
60% of the cases. The oblique fissure is usually visible in
X-ray chest lateral view.
Oblique fissure of left lung is more vertical than the
oblique fissure of the right lung.
Identification of the completeness of the fissure: It is
important before performing lobectomy (i.e., removal of
the lobe of the lung because individuals with incomplete
fissures are more prone to develop postoperative air
leakage than those with complete fissures).
Accessory lobes and fissures
Lobe of azygos vein (Fig. 18.7): Sometimes the medial
part of the superior lobe is partially separated by a
fissure of variable length, which contains the terminal
part of the azygos vein, enclosed in the free margin of a
mesentery derived from the mediastinal pleura. This is
termed lobe of azygos vein. It varies in size and
sometimes includes the apex of the lung.
A left horizontal fissure is a normal variant found in 10%
of the individuals.
ROOT OF THE LUNG

The root of lung is a short broad pedicle connecting the
medial surface of the lung with the mediastinum. It consists
of structures entering and leaving the lung at hilum.
1. Principal bronchus in the left lung, and eparterial and

hyparterial bronchi in the right lung.
2. Pulmonary artery.
3. Pulmonary veins (two in number).
4. Bronchial arteries (one on the right side and two on the
left side).
5. Bronchial veins.
6. Lymphatics of the lung.
7. Anterior and posterior pulmonary plexuses of the
nerves.
N.B. The root of lung lies opposite the bodies of T5, T6,
and T7 vertebrae.
ARRANGEMENT OF STRUCTURES IN THE ROOT OF THE

LUNG AT THE HILUM (Fig. 18.8)
The arrangement of structures in the roots of the lungs is as
follows:
1. From before backwards (it is more or less similar on
two sides):
(a) Pulmonary vein (superior)
(b) Pulmonary artery
(c) Bronchus (left principal bronchus on the left side,
and eparterial, and hyparterial bronchus on the
right side).
Mnemonic: VAB (Vein, Artery, and Bronchus).
2. From above downwards (it differs on two sides):
Right side
Left side
Eparterial bronchus
Pulmonary artery
Pulmonary artery
Left principal bronchus
Hyparterial bronchus
Inferior pulmonary vein
Inferior pulmonary vein
N.B. The difference in the arrangement of structures from

above downwards on the two sides is because right principal
bronchus before entering the lung at hilum divides into two
lobar bronchi, the upper lobar bronchus passes above the
pulmonary artery (eparterial bronchus) and lower lobar
bronchus passes below the pulmonary artery (hyparterial
bronchus).
239
240
Eparterial
bronchus
Right pulmonary
artery
Left pulmonary
artery
Bronchial
arteries
Superior pulmonary
vein
Superior pulmonary
vein
Hyparterial
bronchus
Left principal
bronchus
Inferior pulmonary
vein
Inferior pulmonary
vein
Superior
Superior
Posterior
Anterior
Anterior
Posterior
Pulmonary
ligament
Inferior
Inferior
Fig. 18.8 Arrangement of structures in the roots of right and left lungs.
RELATIONS OF THE ROOT OF THE LUNG

Anterior:
Phrenic nerve.
Anterior pulmonary plexus.
Superior vena cava (on right side only).
Posterior:
Vagus nerve.
Posterior pulmonary plexus.
Descending thoracic aorta (on left side only).
Superior:
Arch of azygos vein (on right side only).
Arch of aorta (on left side only).
Inferior:
Pulmonary ligament.
Hilar shadow in chest radiograph: In X-ray chest
posteroanterior (PA) view, the root of each lung casts a
radiopaque shadow called hilar shadow in the medial
one-third of the lung field. The shadow is in fact cast by
pulmonary vessels when seen end on. The enlargements of
bronchopulmonary lymph nodes (hilar lymph nodes)
increase the density of the hilar shadows.
The differences between the right and left lungs are given
in Table 18.2.
SURFACE MARKINGS (Fig. 18.9)

1. Margins: The lung margins approximately coincide with
those of the pleura (see page 241), except at the following
points:
(a) Lower border: The lower border of each lung is tworib spaces higher than the lower border of the
pleura. Thus, it lies along the line, which cuts
(i) 6th rib in the midclavicular line,
(ii) 8th rib in the midaxillary line, and
(iii) 10th rib at the lateral border of erector spinae
and ends 2 cm lateral to the spine of T10
vertebra.
(b) Anterior border: The anterior border of the left lung
has a distinct notch (the cardiac notch), which
passes laterally behind the 4th and 5th intercostal
spaces.
(c) Posterior border: Its lower end ends at the level of
spine of T10 vertebra.
2. Fissures
(a) The oblique fissure is marked by a line drawn
obliquely downwards and outwards from 1 inch
(2.5 cm) lateral to the T5 spine to the 6th costal
cartilage about 1 inches (4 cm) from the midline.
In clinical practice, ask the patients to abduct the
shoulder to its full extent; the line of oblique fissure in
Table 18.2 Differences between the right and left lungs

Size and shape
Weight
Lobes
Fissure
Anterior border
Hilum
Right lung
Larger, shorter, and broader
700 g
Three (upper, middle, and lower)
Two (horizontal and oblique)
Straight
Two bronchi (eparterial and hyparterial)
Left lung
Smaller, longer, and narrower
650 g
Two lobes (upper and lower)
One (oblique)
Not straight (presents a cardiac notch)
One bronchus (left principal bronchus)
Lungs (Pulmones)
Cervical pleura
Apex of lung
2
4
Horizontal fissure
6
Cardiac notch
Oblique fissure
8
Costodiaphragmatic
recess
Right costoxiphoid
angle
10
Oblique fissure
Anteriorly: The right side of chest primarily presents upper

and middle lobes separated by the horizontal fissure at
about the 5th rib in the midaxillary line to 4th rib at the
sternum. The left side of chest primarily presents upper
lobe, which is separated from the lower lobe by oblique
fissure extending from the 5th rib in the midaxillary line to
the 6th rib at the midclavicular line.
Posteriorly: Except for apices, posterior aspect of chest
on either side primarily presents lower lobe extending
from spinous process of T3T10 or T12 vertebrae.
Right lateral: The lung lies deep to the area extending
from axilla to the level of the 7th or 8th rib. The upper lobe
is demarcated at the level of the 5th rib in the midaxillary
line and 6th rib in the midclavicular line.
Left lateral: The lung lies deep to the area extending from
axilla to the 7th or 8th rib. The upper lobe is demarcated at
the level of the 5th rib in the midaxillary line and 6th rib in
the midclavicular line.
Site of sternal angle
Sternoclavicular
joint
Level of 4th
costal cartilage
Area of superficial
cardiac dullness
6th costal
cartilage
6th rib
Just above the
xiphisternal joint
8th rib
Fig. 18.9 Surface markings of the lung and pleura on the

front: A, shows the relationship of lungs and pleurae in the
thoracic case; B, shows outlines of lung and pleura. Note
outline of lung are shown by blue line and pleura by red line.
this position corresponds to the medial border of the

rotated scapula.
(b) The transverse fissure is marked by a line drawn
horizontally along the 4th costal cartilage, and
meets the oblique fissure where the latter crosses the
5th rib.
Auscultation of lungs: Visualization of lungs from the
surface for listening lung sounds (Fig. 18.10): During
auscultation of lung sounds, it is of utmost importance for the
clinicians to visualize the lungs from the surface as follows:
N.B. Key points to remember during auscultation of lungs:

The superior lobe of the right lung is audible above the
4th rib.
The middle lobe of the right lung is audible between the
4th and the 6th rib.
The lower lobes of both lungs are audible below the 6th
rib on the front.
The inferior lobes of the right and left lungs are best
examined on the back, especially in the region of the
triangle of auscultation.
INTERNAL STRUCTURE
The lung is mainly made up of intrapulmonary bronchial
tree, which is concerned with the conduction of air to-andfro from the lung, and pulmonary units, which are concerned
with the gaseous exchange within the lung (for detailed
structure see textbooks on Histology).
BRONCHIAL TREE (Fig. 18.11)

The bronchial tree consists of principal bronchus, lobar
bronchi, terminal bronchioles, and respiratory bronchioles.
Principal Bronchi (Figs 18.12 and 18.13)

The trachea divides outside the lungs, at the level of the lower
border of T4 vertebra, into two primary (principal)
bronchiright and left for right and left lung, respectively:
1. Right principal bronchus is shorter, wider, and more
vertical. It is about 1 inch (2.5 cm) long and lies more or
less in line with the trachea.
2. Left principal bronchus is narrower, longer, and more
horizontal than the right. It is about 2 inches (5 cm)
long and does not lie in line with the trachea.
241
242
LUL
4th rib
RUL
5th rib in the
midaxillary line
RUL
LUL
RML
RLL
LLL
RLL
LLL
Spinous process
of T10
Spinous process
of T12
6th rib in the

midclavicular line
Anterior
Spinous process
of T3
Posterior
RUL
LUL
4th rib
5th rib in the

midaxillary line
Spinous process
of T3
Spinous process
of T3
RML
RLL
6th rib in the

midclavicular line
LLL
6th rib in the

midclavicular line
Right lateral
Left lateral
Fig. 18.10 Surface projection of different lobes of lungs (RUL = right upper lobe, LUL = left upper lobe, RML = right middle
lobe, RLL = right lower lobe, LLL = left lower lobe).
The long axis of right principal bronchus deviates about 25

from the long axis of the trachea, whereas long axis of the left
principal deviates about 45 from the long axis of the trachea.
The left principal bronchus passes to the left below the
arch of aorta and in front of the esophagus.
Aspiration of foreign body into the right principal
bronchus: The inhaled foreign bodies usually enter in the
right principal bronchus because it is shorter, wider and in
line with the trachea. Since the inhaled foreign particles
tend to enter in the right principal bronchus, hence in the
right lung. As a result, lung abscess occurs more
commonly in the right lung.
Bronchoscopy (Fig. 18.14): It is a procedure, in which a
flexible, fibre-optic bronchoscope is introduced in the
trachea to visualize the interior of the trachea and bronchi.
The carina, a keel-like median ridge at the bifurcation of
the trachea is an important landmark visible through the
bronchoscope. The widening and distortion of the angle
between the principal bronchi (distorting the position of
carina) seen in bronchoscopy is serious prognostic sign,

since it usually indicates carcinomatous involvement of
tracheobronchial lymph nodes. The carina of trachea is
also a very sensitive area for cough reflex.
Bronchiogenic carcinoma: It is the commonest cancer
in the males especially in chronic cigarette smokers. It
usually arises from epithelial lining of the bronchi and
forms well-circumscribed grey white mass in the lung.
A presence of circular shadow (popularly called
coin-shadow) in plane X-ray chest (PA view) may be the
only finding in an otherwise asymptomatic patient.
The bronchiogenic carcinoma may spread (metastasis) to
brain by both arterial and venous routes as under:
Arterial root
Lung capillaries pulmonary vein left atrium left
ventricle aorta internal carotid and vertebral
arteries brain
Venous route
Bronchial veins azygos vein external vertebral
venous plexus internal vertebral venous plexus
cranial dural venous sinuses brain.
Lungs (Pulmones)
Trachea
Trachea
Lobar (secondary)
bronchus
Segmental (tertiary)
bronchus
Terminal bronchus
Lobar bronchiole
Conducting portion
Principal (primary)
bronchus
Right
bronchus
Left
bronchus
45
25
Terminal bronchiole
Respiratory bronchiole
Respiratory portion
Fig. 18.13 Trachea and principal bronchi.
Alveolar duct
Atrium
Alveolar sac
Carina
Alveoli
Fig. 18.11 Bronchial tree.
Thoracic duct
Esophagus
Left vagus nerve
Trachea
Arch of aorta
Arch of azygos
vein
Left main bronchus
Right main bronchus
Left recurrent
laryngeal nerve
Left principal
bronchus
Fig. 18.14 Lower end of trachea and its main branches as

seen on bronchoscopy. (Source: Fig. 3.48A, Page 151,
Gray's Anatomy for Students, Richard L Drake, Wayne Vogl,
Adam WM Mitchell. Copyright Elsevier Inc. 2005, All rights
reserved.)
Right principal
bronchus
TERTIARY (SEGMENTAL) BRONCHI

Fig. 18.12 Relation of principal bronchi.
LOBAR BRONCHI
On entering the lung, the right principal bronchus divides
(gives off) three lobar bronchi, one for each lobe of the right
lung. The left principal bronchus on entering the lung divides
into two lobar bronchi, one for each lobe of the left lung.
Each lobar bronchus divides into segmental (tertiary)

bronchi, one for each bronchopulmonary segment.
The segmental bronchi divide repeatedly to form very
small bronchi called terminal bronchioles. The terminal
bronchioles give off respiratory bronchioles, which lack
cartilage in their walls.
Each respiratory bronchiole aerates a small portion of
lung called pulmonary units, which is concerned with
gaseous exchange within the lung.
243
244
PULMONARY UNITS
Aortic arch
Right pulmonary
artery
Each pulmonary unit consists of

(a)
(b)
(c)
(d)
Trachea
Azygos arch
alveolar ducts,
atria,
air saccules, and
alveoli.
N.B.
The respiratory bronchiole represents the transitional
zone/part between the conducting and respiratory
portions of the respiratory system.
The alveoli are specialized sac-like structures which form
greater part of the lungs. They are the main sites for the
gaseous exchange of oxygen and carbon dioxide
between the inspired air and blood.
Left pulmonary
artery
Pulmonary
trunk
Fig. 18.15 Relationship of the pulmonary arteries to bronchi.
Emphysema: In this condition, alveoli of lungs are damaged
by chemicals released by pollutants. Clinically it presents as
shortness of breath and the chest appears barrel shaped in
chest radiograph.
ARTERIAL SUPPLY OF THE LUNGS

The lungs are supplied by two sets of arteries, viz.
1. Bronchial arteries.
2. Pulmonary arteries.
BRONCHIAL ARTERIES
The bronchial arteries supply nutrition to the bronchial tree
and pulmonary tissue.
The right lung is supplied by one bronchial artery, which
arises from the right third posterior intercostal artery or
from upper left bronchial artery. The left lung is supplied by
two bronchial arteries, which arise from descending thoracic
aorta.
VENOUS DRAINAGE
The venous blood from lungs is also drained by two sets of
veins, viz.
1. Bronchial veins.
2. Pulmonary veins.
Bronchial veins: The bronchial veins drain the deoxygenated
blood from the bronchial tree and pulmonary tissue. There
are two bronchial veins on each side:

The right bronchial veins drain into azygos veins.

The left bronchial veins drain into hemiazygos vein or left
superior intercostal vein.
Pulmonary veins: The pulmonary veins drain the

oxygenated blood from the lungs. There are two pulmonary
veins on each side.
The pulmonary veins do not accompany the pulmonary
arteries. The tributaries of pulmonary veins are
intersegmental, while branches of pulmonary arteries are
segmental in distribution.
PULMONARY ARTERIES
The pulmonary arteries supply deoxygenated blood to the
lungs. There is one pulmonary artery for each lung. They are
the branches of the pulmonary trunk.
The right and left pulmonary arteries lie anterior to the
principal (primary) bronchi as they enter the hilum of their
respective lungs. The right pulmonary artery is crossed
superiorly by the arch of the azygos vein; whereas the left
pulmonary artery lies inferior to the arch of aorta, at the level
of T5 vertebra. The pulmonary arteries divide into lobar
branches in the hilum and subsequently divide into terminal/
segmental branches. The segmental branches, branch
successively corresponding with the segmental branches of
the bronchial tree (Fig. 18.15).
N.B.
All the veins in the body drain deoxygenated blood
except pulmonary veins, which drain the oxygenated
blood from the lungs.
All the arteries of the body supply oxygenated blood
except pulmonary arteries, which supply deoxygenated
blood to the lungs.
The bronchial arteries provide nutrition to the bronchial
tree, as far as the respiratory bronchioles, i.e., nonrespiratory portions of the lungs.
The respiratory portions of the lungs are nourished by
pulmonary capillary beds and atmospheric air in the
alveoli.
Lungs (Pulmones)
Pretracheal nodes
Paratracheal nodes
Superior tracheobronchial nodes
Hilar (bronchopulmonary) nodes
Superficial lymph vessels
Deep lymph vessels
Visceral pleura
Inferior tracheobronchial nodes
Fig. 18.16 Lymphatic drainage of the lungs.
LYMPHATIC DRAINAGE
The lymphatic drainage of the lung is clinically important
because lung cancer spreads by lymphatic path.
The lymph from the lung is drained by two sets of lymph
vessels (Fig. 18.16):
1. Superficial vessels.
2. Deep vessels.
Superficial lymph vessels: These vessels drain the
peripheral lung tissue lying beneath the visceral pleura.
They form the superficial (subpleural) plexus beneath the
visceral pleura. The vessels from plexus pass around the
borders and margins of the fissures of lung to reach the
hilum where they drain into the bronchopulmonary (hilar)
lymph nodes.
Deep lymph vessels: These vessels drain the bronchial tree,
pulmonary vessels, and connective tissue septa and form
deep plexus. The vessels from deep plexus run along the
bronchi and pulmonary vessels towards the hilum of the
lung passing through pulmonary lymph nodes located
within the lung substance, and finally drain into
bronchopulmonary (hilar) lymph nodes.
Thus both superficial and deep lymphatic plexuses drain
into bronchopulmonary (hilar) lymph nodes. From hilar
lymph nodes, the lymph is drained into the superior and
inferior tracheobronchial lymph nodes located superior and
inferior to the bifurcation of the trachea, respectively. These

nodes in turn drain into pre- and paratracheal lymph nodes,
and right and left bronchomediastinal lymph trunk, which
finally drain into right lymphatic duct and thoracic duct on
the right and left sides respectively.
N.B. All the lymph from the lung is drained into
tracheobronchial lymph nodes (located at the hilum), which
in turn drain into bronchomediastinal lymph nodes.
NERVE SUPPLY
The lung is supplied by both parasympathetic and
sympathetic nerve fibres:
The parasympathetic fibres are derived from the vagus
nerve and sympathetic fibres are derived from T2 to T5
spinal segments. Both provide motor supply to the bronchial
muscles and secretomotor supply to the mucous glands of
the bronchial tree.
The parasympathetic fibres cause bronchoconstriction/
bronchospasm, vasodilatation, and increased mucous
secretion. The sympathetic fibres cause bronchodilatation,
vasoconstriction, and decreased mucous secretion.
The afferent impulse arising from the bronchial mucous
membrane and stretch receptors in the alveolar walls pass to
the central nervous system through both sympathetic and
parasympathetic fibres.
245
246
Table 18.3 Bronchopulmonary segments
Lobes
Bronchial asthma: It is a common disease of the

respiratory system. It occurs due to bronchospasm (spasm
of smooth muscle in the wall of bronchioles) which
reduces the diameter of the bronchioles. As a result,
patient has great difficulty during expiration, although
inspiration is accomplished normally. The airflow is further
impeded due to presence of excessive mucous which the
patient is unable to clear because an effective cough
cannot be produced. Clinically the asthma is characterized
by (a) difficulty in breathing (dyspnea) and (b) wheezing.
The sympathomimetic drugs such as epinephrine cause
vasodilatation and relieve the bronchial asthma.
Bronchiectasis: It is a clinical condition, in which bronchi
and bronchioles are dilated permanently as a result of
chronic necrotizing infection. They become filled with pus
leading to airway obstruction. The basal segments of the
lower lobe are prone to this condition.
Aspiration pneumonia: In supine position, aspirated
material usually enters into superior (apical segment) of
the lower lobe, especially on the right side for it is the most
dependent segment in this position. It leads to collection
of secretions which may obstruct the bronchus leading to
collapse of the superior segment of the lower lobe
(atelectasis) and pneumonia.
Right lung
Superior
Segments
1. Apical
2. Posterior
3. Anterior
Middle
4. Lateral
5. Medial
Inferior
6. Superior (apical)
7. Medial basal
8. Anterior basal
9. Lateral basal
10. Posterior basal
Left lung
Superior
1. Apical
2. Posterior
3. Anterior
4. Superior lingular
5. Inferior lingular
Inferior
6. Superior (apical)
7. Medial basal
BRONCHOPULMONARY SEGMENTS
8. Anterior basal
The bronchopulmonary segments are well-defined, wedgeshaped sectors of the lung, which are aerated by tertiary
(segmental) bronchi (Fig. 18.17).
9. Lateral basal
10. Posterior basal
Intersegmental planes
Pulmonary venule in
intersegmental plane
Pulmonary artery
(segmental branch)
Tertiary/segmental
bronchus
Bronchial artery
(segmental branch)
III
II
Fig. 18.17 Schematic diagram showing three bronchopulmonary segments (I, II, and III).
Lungs (Pulmones)
Characteristic features:
1. It is a subdivision of the lobe of the lung.
2. It is pyramidal in shape with apex directed towards the
hilum and base towards the surface of the lung.
3. It is surrounded by the connective tissue.
4. It is aerated by the segmental (tertiary) bronchus.
5. Each segment has its own artery, a segmental branch of
the pulmonary artery.
6. Each segment has its own lymphatic drainage and
autonomic supply.
1
2
4
5
Upper lobe
bronchus
8
10
Lingular
bronchus
6
4
Thus, bronchopulmonary segments are the well-defined

anatomical, functional, and surgical units of the lungs.
N.B. The segmental veins (the tributaries of pulmonary veins)

run in the intersegmental planes of the connective tissue.
Lower lobe
bronchus
6
4
NUMBER AND NOMENCLATURE OF

BRONCHOPULMONARY SEGMENTS
(Figs 18.18 and 18.19)
10
1
2
6
4
5
8
10
Lower lobe
bronchus
10
7
8
B
10
Fig. 18.19 Bronchopulmonary segments of the left lung as

seen on: A, lateral aspect; B, medial aspect; C, lobar and
segmental bronchi.
5
1
Upper lobe
bronchus
Middle lobe
bronchus
There are 10 segments in each lung. They are named and

numbered in Table 18.3. The bronchopulmonary segments
of right and left lungs are shown in Figures 18.18 and 18.19
respectively.
1
3
5
9
The number and terms used to designate the segments vary

among different authors, but in this book, the number and
terms accepted by the International Congress of Anatomists,
(1960) has been adopted.
Segmental resection of the lung: The knowledge of the

bronchopulmonary segments has led to the advancement in
conservation lung surgery. Since each segment is an
independent functional unit having its own bronchovascular
supply and potential planes of separation exist between the
segments. Localized chronic disease, such as tuberculosis,
bronchiectasis or benign neoplasm is restricted to one
segment; it is, therefore, possible to dissect out and remove
the diseased segment leaving the surrounding tissue intact.
This procedure is called segmental resection.
8
10
Fig. 18.18 Bronchopulmonary segments of the right lung

as seen on: A, lateral aspect; B, medial aspect; C, lobar and
segmental bronchi.
N.B.
During segmental dissection, it is important not to ligate
intersegmental veins as they will interfere with the venous
drainage of the surrounding healthy segments.
Segmental resection is most often carried out in
bronchiectasis.
247
CHAPTER
19
Mediastinum
The mediastinum (L. middle septum) is the median septum

of thoracic cavity between the two pleural cavities. It consists
of all the viscera and structures of the thoracic cavity (e.g.,
heart and its great blood vessels, esophagus, trachea and
principal bronchi, aorta, mediastinal lymph nodes, etc.)
except the lungs. The mediastinum occupies the central
compartment of the thoracic cavity. Thus strictly speaking, it
is a broad central partition, which separates the two laterally
placed pleural cavities (Fig. 19.1). It is covered on either side
by the mediastinal pleura.
BOUNDARIES (Figs 19.2 and 19.4)

Sternum.
Vertebral column (bodies of thoracic vertebrae
and intervening intervertebral discs).
Superior:
Superior thoracic aperture.
Inferior:
Diaphragm.
On each side: Mediastinal pleura.
N.B. The mediastinum is not a rigid structure as observed

by the students in the cadaver (embalmed dead body). In a
living individual, mediastinum is a highly mobile septum
because it consists primarily of hollow visceral structures
bound together by loose connective tissue, often infiltrated
with fat.
CONTENTS
The major contents of mediastinum are (Fig. 19.2):
1. Thymus.
2. Heart enclosed in the pericardial sac.
Anterior:
Posterior:
Left common carotid

artery
Thoracic inlet
Right pulmonary
artery
Mediastinum
Right pleural
cavity
Trachea
Left pleural
cavity
Left subclavian
artery
T1
Left subclavian
artery
Left principal
bronchus
Thymus
Sternum
Heart
Diaphragm
IVC
Esophagus
T12
Aorta
Fig. 19.1 Cross section of the thorax showing the position

of the mediastinum.
Fig. 19.2 Boundaries and contents of the mediastinum.

Note that all the mediastinal structures are not depicted
(IVC =inferior vena cava).
250
3. Major arteries and veins such as thoracic aorta,

pulmonary trunk, etc.
4. Trachea.
5. Esophagus.
6. Thoracic duct.
7. Neural structures, such as sympathetic trunks, vagus

nerves, phrenic nerve, etc.
8. Lymph nodes.
The structures forming the right and left surfaces of the
mediastinum as shown in Figure 19.3.
Esophagus
Trachea

Azygos vein
Superior vena cava

Root of right lung
1. Sympathetic chain
2. Right vagus nerve
Right atrium covered

with pericardium
3. Right phrenic nerve
Trachea
Left common carotid
artery
Esophagus
Thoracic duct
Arch of aorta
Left vagus nerve
Left recurrent
laryngeal nerve
Root of left lung

Left ventricle covered

by pericardium
1. Sympathetic chain
2. Left vagus nerve
3. Left phrenic nerve
Fig. 19.3 Mediastinal structures as seen from its lateral aspect in sagittal section of the thorax: A, right side; B, left side.
Mediastinum
DIVISIONS
For the purpose of description and organization of structures
the mediastinum is artificially divided into two parts:
(a) superior mediastinum and (b) inferior mediastinum by
an imaginary plane (transverse thoracic plane) passing
through the sternal angle anteriorly, and lower border of the
body of the fourth thoracic (T4) vertebra/intervertebral disc
T4 and T5 vertebrae posteriorly.
The inferior mediastinum is further subdivided into three
parts by the pericardium (enclosing heart). The part in front
of the pericardium is called anterior mediastinum, and the
part behind the pericardium is called posterior mediastinum.
The pericardium and its contents (heart and roots of its great
vessels) constitute the middle mediastinum (Fig. 19.4).
The divisions and subdivisions of the mediastinum are
shown in Flowchart 19.1.
Vertebral column
(thoracic vertebrae and
intervening intervertebral
discs)
T1
Plane of superior
thoracic inlet
Superior mediastinum
T4
Sternal plane
Inferior mediastinum
Sternum
Visualization of subdivisions of mediastinum in chest

radiograph: The subdivisions of mediastinum are
well-appreciated in lateral view of X-ray chest (Fig. 19.5).
The shadow above the sternal plane represents superior
mediastinum.
The subdivisions of inferior mediastinum are demarcated
as under:
(a) cardiac shadow above the anterior part of diaphragm
represents the middle mediastinum.
(b) retrosternal space/space in the front of cardiac shadow
represents the anterior mediastinum.
(c) retrocardiac space/space between the cardiac shadow
and shadow of vertebral column represents the
posterior mediastinum.
SUPERIOR MEDIASTINUM
Anterior:
Manubrium sterni.
Posterior:
Bodies of upper four thoracic vertebrae.
Superior:
Plane of superior thoracic aperture.
Inferior:
An imaginary plane passing through the
sternal angle in front and lower border of the
body of fourth thoracic vertebra behind
(transverse thoracic plane).
On each side Mediastinal pleura.
(lateral):
Anterior mediastinum
Middle mediastinum
Posterior mediastinum
Superior
Diaphragm
Anterior
T12
Middle
Posterior
Fig. 19.4 Divisions of the mediastinum.
Mediastinum
Anterior
mediastinum
Inferior mediastinum
Middle
mediastinum
Posterior
mediastinum
Flowchart 19.1 Divisions and subdivisions of the mediastinum.
Fig. 19.5 Parts of the mediastinum demonstrated on a chest

radiograph (lateral view). (Source: Fig. 4.13, Page 99, Integrated
Anatomy, David JA Heylings, Roy AJ Spence, Barry E Kelly.
Copyright Elsevier Limited 2007, All rights reserved.)
251
252
Contents (Figs 19.6 and 19.7)

1. Arteries
(a) Arch of aorta.
(b) Brachiocephalic artery.
(c) Left common carotid artery.
(d) Left subclavian artery.
2. Veins
(a) Right and left brachiocephalic veins.
(b) Upper half of the superior vena cava (SVC).
(c) Left superior intercostal vein.
3. Nerves
(a) Phrenic nerves (right and left).
(b) Vagus nerves (right and left).
(c) Sympathetic trunks and cardiac nerves (right and

left).
(d) Left recurrent laryngeal nerves.
4. Lymphoid organs and lymphatics
(a) Lymph nodes.
(b) Thoracic duct.
(c) Thymus.
5. Tubes
(a) Trachea.
(b) Esophagus.
6. Muscles
(a) Sternohyoid.
(b) Sternothyroid.
(c) Longus colli.
Esophagus
Trachea
Right vagus nerve
Left common carotid

artery
Left recurrent laryngeal
nerve

Superior vena cava
Left superior intercostal

vein
Left vagus nerve
Arch of aorta
Pericardium
Fig. 19.6 Arrangement of structures in the superior mediastinum as seen in dissection. Note that great veins are anterior to
the great arteries.
Left sympathetic chain

Right sympathetic
chain
Esophagus
Trachea
Longus colli
Thoracic duct
Recurrent laryngeal nerve
Right vagus nerve

Right phrenic nerve
Right brachiocephalic
vein
Thymus

Left vagus nerve
Left phrenic nerve
Sternothyroid
Sternohyoid
Fig. 19.7 Transverse section of superior mediastinum showing the arrangement of its contents.
Mediastinum
N.B. For the purpose of orientation during surgery, the

major structures of superior mediastinum are arranged in
the following order from anterior to posterior:
Thymus
Large veins
Large arteries
Trachea
Esophagus and thoracic duct
Sympathetic trunks.
Azygos vein
ANTERIOR MEDIASTINUM
Anterior:
Body of sternum.
Posterior:
Pericardium enclosing heart.
Superior:
Transverse thoracic plane separating superior
and inferior mediastinum.
Inferior:
Diaphragm.
On each side: Mediastinal pleura.
Contents
1. Loose areolar tissue.
2. Superior and inferior sternopericardial ligaments
stretching between sternum and pericardium.
3. Three or four lymph nodes.
4. Mediastinal branches of internal thoracic (mammary)
arteries.
5. Lower portion of thymus (in children).
The anterior mediastinum is a very narrow space. It is
continuous through superior mediastinum with the
pretracheal space of the neck. Therefore, neck infection in
pretracheal space may spread into the anterior mediastinum.
Ascending aorta
HEART
Fig. 19.8 Main contents of the middle mediastinum.
Superior:
Inferior:
Superior mediastinum.
Diaphragm.
Contents (Fig. 19.8)

1. Heart
2. Pericardium
3. Arteries:
(a) Ascending aorta
(b) Pulmonary trunk dividing into two pulmonary
arteries
(c) Pericardiophrenic arteries
4. Veins:
(a) Superior vena cava (lower half)
(b) Azygos vein (terminal part)
(c) Pulmonary veins (right and left)
5. Nerves:
(a) Phrenic nerves
(b) Deep cardiac plexus
6. Lymph nodes:
(a) Tracheobronchial lymph nodes
7. Tubes:
(a) Bifurcation of trachea
(b) Right and left principal bronchi
N.B. The main contents of middle mediastinum are
pericardium and its contents (e.g., the heart and roots of its
great vessels).
POSTERIOR MEDIASTINUM
MIDDLE MEDIASTINUM
Anterior:
Anterior mediastinum.
Posterior:
Posterior mediastinum.
Left pulmonary
veins
Right pulmonary
veins
Potential dead space in superior mediastinum: In
superior mediastinum, all large veins (superior vena cava,
right and left brachiocephalic veins) are on the right side
and all the large arteries (arch of aorta and its three
branches) are on the left side. Consequently, during
increased blood flow, the large veins expand enormously
while the large arteries do not expand at all. This is because
there is sufficient dead space on the right side. It is into this
space that tumors of mediastinum tend to project.
Pulmonary
trunk
Superior vena
cava

Anterior:
(a) pericardium and its contents, (b) bifurcation

of the trachea, and (c) pulmonary vessels.
253
CHAPTER
20
PERICARDIUM
The pericardium (G. around heart) is a fibroserous sac which
encloses the heart and the roots of its great blood vessels. The
pericardium lies within the middle mediastinum, posterior
to the body of the sternum and 2nd6th costal cartilages and
anterior to the middle four thoracic vertebrae (i.e., from T5
to T8).
The functions of the pericardium are:
(a) restricts excessive movements of the heart,
(b) serves as a lubricated container in which heart can
contract and relax smoothly, and
(c) limits the cardiac distension.
The heart and great vessels lie inside the fibrous sac and
invaginate the serous sac from behind during development.
As a result, the external surface of the heart and internal
surface of the fibrous pericardium are covered by a layer of
serous pericardium. The layer covering the surface of the
heart is called visceral pericardium or epicardium and the
layer covering the inner aspect of the fibrous pericardium is
called parietal pericardium. The intervening potential space
between the two serous layers is called pericardial cavity
(Fig. 20.1).
The pericardium thus consists of three layers (Fig. 20.2).
From outside to inwards these are:
1. Fibrous layer of the pericardium.
2. Parietal layer of the serous pericardium.
3. Visceral layer of the serous pericardium (epicardium).
SUBDIVISIONS
The pericardium consists of two components:
(a) an outer single layered fibrous sac called fibrous
pericardium, and
(b) inner double layered serous sac called serous
pericardium.
A little description of embryology makes it easier to
understand the formation of different layers of the
pericardium.
FIBROUS PERICARDIUM
The fibrous pericardium is strong fibrous sac which supports
the delicate parietal layer of the serous pericardium with
which it is firmly adherent.
Features
The features of fibrous pericardium are as follows:
1. It is conical in shape.
Large blood vessel

Developing heart
Serous
pericardium
Fibrous
pericardium
Parietal layer of
serous pericardium
Pericardial
cavity
Heart
Visceral layer of
serous pericardium
Pericardial cavity
Fig. 20.1 Development of different layers of the pericardium.
258
Superior vena cava

Ascending aorta
Pulmonary trunk
Transverse sinus
Visceral layer of
serous pericardium
SVC
Right pulmonary veins
Left pulmonary veins

Visceral layer of
serous pericardium
Parietal layer of
serous pericardium
IVC
Oblique sinus
Fig. 20.3 Interior of the serous pericardial sac after section of the large vessels and removal of the heart showing transverse
and oblique pericardial sinuses (SVC = superior vena cava, IVC = inferior vena cava).
Parietal pericardium
Right auricle
Pulmonary trunk
Ascending aorta
Right atrium
Left auricle
Arrow in transverse
pericardial sinus
Left pulmonary
vein
Crista terminalis
Left atrium
Right pulmonary vein
Oblique sinus of
pericardium
Fig. 20.4 Cross section of heart through the atria showing reflection of pericardium and formation of transverse and oblique
pericardial sinuses. Note that the left atrium lies behind the pulmonary trunk and aorta, from which it is separated by
transverse sinus of the pericardium.
It is a horizontal passage between the two pericardial

tubes. On each side it communicates with the general
pericardial cavity.
Oblique Sinus of Pericardium

It is a recess of serous pericardium behind the base of the
heart (actually left atrium). It is enclosed by J-shaped sheath
of visceral layer of serous pericardium enclosing six veins

(i.e., 2 vena cavae and 4 pulmonary veins).
The oblique sinus is akin to lesser sac behind the stomach
and develops as a result of absorption of four pulmonary
veins into the left atrium. The oblique sinus permits the
distension of left atrium during return of oxygenated blood
in it from the lungs.
Boundaries
Oblique sinus of pericardium is bounded in the following
way:
Anteriorly:
by left atrium.
Posteriorly:
by parietal pericardium.
On right side:
by reflection of visceral pericardium along
the right pulmonary veins and inferior
vena cava.
On the left side: by reflection of visceral pericardium along
the left pulmonary veins.
Superiorly:
by reflection of visceral pericardium along
the right and left superior pulmonary veins.
Inferiorly:
it is open.
NERVE SUPPLY
1. The fibrous pericardium and parietal layer of the serous
pericardium are supplied by the phrenic nerves (somatic
nerve fibres).
2. The visceral layer of the serous pericardium is supplied
by the branches of sympathetic trunks and vagus nerves
(autonomic nerve fibres). Thus fibrous pericardium and
parietal layer of the visceral pericardium are sensitive to
pain whereas visceral layer of pericardium is insensitive
to pain. Consequently pain of pericarditis originates
from parietal pericardium.
Surgical significance of transverse pericardial sinus:
During cardiac surgery, after the pericardial sac is opened
anteriorly, a finger is passed through the transverse sinus
of pericardium, posterior to the aorta and pulmonary trunk
(Fig. 20.5).
A temporary ligature is passed through the transverse
sinus around the aorta and pulmonary trunk. The tubes of
heart-lung machine are inserted into these vessels and
ligature is tightened.
ARTERIAL SUPPLY
The fibrous pericardium and parietal layer of visceral

pericardium is supplied by the branches of the following
arteries:
1. Internal thoracic artery.
2. Musculophrenic arteries.
3. Descending thoracic aorta.
The visceral layer of serous pericardium is supplied by the
coronary arteries.
Pericarditis and cardiac tamponade: The inflammation

of the serous pericardium is called pericarditis which
causes accumulation of serous fluid in the pericardial
cavity, the pericardial effusion. The excessive
accumulation of serous fluid in the pericardial cavity may
compress the thin-walled atria and interfere with the filling
of the heart during diastole and consequently the cardiac
output is diminished. This condition is clinically termed
cardiac tamponade.
The pericarditis is the terminal event in uremia.
Pericardiocentesis: Excessive pericardial fluid can be
aspirated from the pericardial cavity by two routes:
Sternal approach: The needle is inserted through the
left 5th or 6th intercostal space immediately adjacent to
the sternum.
Subxiphoid approach: The needle is inserted in the left
costoxiphoid angle and passed in an upward and
backward direction at an angle of 45 to the skin.
Pericardial friction rub: The roughening of parietal and
visceral layers of the serous pericardium by inflammatory
exudate can cause friction between the two layers called
pericardial friction rub which can be felt on palpation and
heard through the stethoscope.
Superior vena
cava
Ascending aorta
Index finger passing
through transverse sinus
Fig. 20.5 Finger passing through the transverse pericardial sinus.
Pulmonary trunk
259
260
HEART
The heart (syn. Gk. Kardia/Cardia; L. Cor/Cordis) is a hollow
muscular organ situated in the mediastinum of the thoracic
cavity, enclosed in the pericardium. It is somewhat pyramidal
in shape and placed obliquely behind the sternum and
adjoining parts of costal cartilages so that one-third of the
heart is to the right of median plane and two-third of the
heart is to the left of the median plane.
The heart consists of four chambersright atrium and
right ventricle, and left atrium and left ventricle. On the
surface the atria are separated from the ventricles by the
atrioventricular groove (also called coronary sulcus) and
ventricles from each other by interventricular grooves.
Shape and Measurements

Shape: Pyramidal or conical.
Measurements: Length = 12 cm.
Width = 9 cm.
Weight = 300 g in males; 250 g in females.
N.B. The heart is slightly larger than ones own clenched fist.
EXTERNAL FEATURES (Figs 20.6 and 20.7)

The heart presents the following external features:
1. Apex.
2. Base.
3. Three surfaces (sternocostal, diaphragmatic, and left)

4. Four borders (right, left, upper, and inferior).
APEX OF THE HEART

The apex of the heart is a conical area formed by left ventricle.
It is directed downwards and forwards, and to the left. It lies
at the level of the 5th left intercostal space, 3.5 inches (9 cm)
from the midline and just medial to the midclavicular line.
Apex beat: It is the outermost and lowermost thrust of
the cardiac contraction (during ventricular systole) felt on
the front of the chest or it is the point of maximum cardiac
impulse (PMCI). Normally the apex beat is felt as a light
tap in left 5th intercostal space in the midclavicular line.
In infants, the heart is positioned more horizontally so
that the apex of the heart lies in third or fourth left intercostal
space and consequently the apex beat in children up to 7
years of age is felt in the third or fourth intercostal space just
lateral to the midclavicular line.
N.B. Normally the apex of the heart is on the left side

and apex beat is felt on the left side (left 5th intercostal
space) but sometimes the heart is malpositioned with
apex on the right side. This condition is called
dextrocardia. It may be associated with complete
reversal of thoracic and abdominal viscera, a condition
called situs inversus.
Superior vena cava

Arch of aorta
Ascending aorta
Pulmonary trunk
Right auricle
Right atrium

Left auricle
Atrioventricular groove
Atrioventricular groove
Right ventricle
Anterior interventricular
groove
Left ventricle
Posterior interventricular
groove
Apex
Fig. 20.6 Anterior aspect (sternocostal surface) of the heart. Note that the most of the sternocostal surface is formed by the
right atrium and the right ventricle.
Arch of aorta
Superior vena cava
Left pulmonary artery
Right pulmonary artery
Left atrium
Right atrium
Coronary sulcus
Left ventricle
Posterior interventricular
groove
Right ventricle
Inferior vena cava
Apex
Fig. 20.7 Posterior aspect of the heart.
BASE OF THE HEART

The base (or posterior surface) of the heart is formed by two
atria, mainly by the left atrium. Strictly speaking two-third of
the base is formed by the posterior surface of the left atrium
and one-third by the posterior surface of the right atrium. It
is directed backwards and to the right (i.e., opposite to the
apex).
Characteristic features of the base are as follows:
1. It lies opposite to the apex.
2. It lies in front of the middle four thoracic vertebrae (i.e.,
T5T8) in the lying-down position and descends one
vertebra in the erect posture (T6T9).
3. The base is separated from vertebral column by the
oblique pericardial sinus, esophagus, and aorta.
N.B. Clinically, base is the upper border of the heart where
great blood vessels (superior vena cava, ascending aorta,
and pulmonary trunk) are attached.
SURFACES OF THE HEART
the anterior part of atrioventricular groove. The sternocostal

surface is also partly formed by the left auricle and left
ventricle. The right ventricle is separated from left ventricle
by the anterior interventricular groove.
N.B.
The left atrium is hidden on the front by the ascending
aorta and pulmonary trunk.
The part of sternocostal surface is uncovered by the left
lung (cardiac notch) forming an area of superficial cardiac
dullness.
Diaphragmatic surface: This surface is flat and rests on the

central tendon of the diaphragm. It is formed by the left and
right ventricles which are separated from each other by the
posterior interventricular groove. The left ventricles form
left two-third of this surface and right ventricle forms only
right one-third of this surface.
Left surface: It is formed mainly by the left ventricle and
partly by the left atrium and auricle. It is directed upwards,
backwards, and to the left.
The heart has the following three surfaces:
BORDERS OF THE HEART
1. Sternocostal (anterior).
2. Diaphragmatic (inferior).
3. Left surface.
The heart has the following four borders:
Sternocostal surface: It is formed mainly by the right atrium

and right ventricle, which are separated from each other by
1.
2.
3.
4.
Right border.
Left border.
Inferior border.
Upper border.
261
Right border: It is more or less vertical and is formed by the

right atrium. It extends from the right side of the opening of
SVC to that of IVC and separates the base from the sternocostal
surface.
Left border: It is curved and oblique. It is formed mainly by
the left ventricle and partly by the left auricle. It extends from
left auricle to the apex of the heart and separates sternocostal
and left surfaces.
Inferior border: It is nearly horizontal and extends from the
opening of IVC to the apex of the heart. It is formed by the
right ventricle. The right atrium also forms a part of this
border. The inferior border separates the sternocostal surface
from the diaphragmatic surface. Near the apex it presents a
notch called incisura apicis cordis.
Upper border: It is slightly oblique and is formed by the right
and left atria, mainly by the latter. The upper border is
obscured from the view on the sternocostal surface because
ascending aorta and pulmonary trunk lie in front of it. On
the surface of the body it can be marked by a line joining a
point on the lower border of the 2nd left costal cartilage, 1.5
in from the median plane to a point on the upper border of
3rd right costal cartilage, 1 inch away from the median plane.
Cardiac shadow in chest radiograph: In X-ray of chest,
PA view, the term cardiac-shadow is used for mediastinal
shadow. The left border of cardiac shadow, from above
downwards is formed by: aortic arch, pulmonary trunk, left
auricle and left ventricle. The right border from above
downwards is formed by SVC and right atrium (Fig. 20.8).
CHAMBERS OF THE HEART

The heart consists of four chambers, viz.
1.
2.
3.
4.
Right atrium.
Right ventricle.
Left atrium.
Left ventricle.
The two atrial chambers are separated from each other by

a vertical septumthe interatrial septum and the two
ventricular chambers are separated from each other by a
vertical septumthe interventricular septum.
The right atrium communicates with the right ventricle
through right atrioventricular orifice, which is guarded by
three cusps.
The left atrium communicates with the left ventricle
through the left atrioventricular orifice, which is guarded by
two cusps.
The walls of the chambers of the heart are made up of
cardiac musclethe myocardium, which is covered
externally by the serous membranethe epicardium and
lined internally by endothelium the endocardium.
The atria are thin walled as compared to the ventricles
and have little contractile power.
Demarcation of Chambers of the Heart on the Surface

On the surface the chambers of the heart are demarcated or
delineated by the following three sulci/grooves (Figs 20.6
and 20.7):
1. Coronary sulcus (atrioventricular groove).
2. Anterior interventricular sulcus.
3. Posterior interventricular sulcus.
Tracheal shadow
Clavicle
S.V
.C
r ta
Ao
262
2
P.T.
Right
cardiophrenic
angle
3
6
R.A.
R.V.
Right costodiaphragmatic
recess
Right dome
of diaphragm
L.V.
Left dome
of diaphragm
Left cardiophrenic
angle
Left costodiaphragmatic
recess
Fig. 20.8 X-ray chest PA view; A, actual radiograph; B, tracing of the cardiac shadow (1 = Aortic knuckle, 2 = Pulmonary
conus, 3 = Left auricle, 4 = Left ventricle, 5 = Superior vena cava, 6 = Right atrium). (Source: A, Fig. 4.1, Page 94, Integrated
Anatomy, David JA Heylings, Roy AJ Spence, Barry E Kelly. Copyright Elsevier Limited 2007, All rights reserved. B; Fig. 3.19, Page
137, Clinical and Surgical Anatomy, 2e, Vishram Singh. Copyright Elsevier 2007, All rights reserved.)
N.B. The meeting point of interatrial groove, posterior

interventricular groove, and posterior part of atrioventricular
groove is termed crux of the heart.
Coronary sulcus (atrioventricular groove): It encircles the

heart and separates the atria from the ventricles. It is deficient
anteriorly due to the root of pulmonary trunk.
The atrioventricular groove is divided into anterior and
posterior parts.
The anterior part consists of right and left halves.
The right half of the anterior part runs downwards and to
the right between the right atrium and right ventricle and
lodges right coronary artery.
The left anterior part of AV groove intervenes between the
left auricle and left ventricle. It lodges circumflex branch of
left coronary artery.
The posterior part of AV groove intervenes between the
base and the diaphragmatic surface of the heart. It lodges
coronary sinus.
Circulation of Blood
Functionally, the heart is made up of two muscular pumps
the right and left (Fig. 20.9). The right pump consists of
right atrium and right ventricle while the left pump consists
of left atrium and left ventricle. The right pump is responsible
for pulmonary circulation and the left pump is responsible
for systemic circulation as follows:
The right atrium receives deoxygenated blood from the
whole body through superior and inferior venae cavae.
The blood flows from right atrium into right ventricle
through right atrioventricular orifice. The blood is
prevented from regurgitating back to the atrium by means
of right atrioventricular valve. The right ventricle contracts
and propels the blood into the pulmonary trunk,
pulmonary arteries, and finally into the lung where blood
is oxygenated (pulmonary circulation).
The left atrium receives the oxygenated blood from lungs
through four pulmonary veins. The blood from left
Anterior and posterior interventricular sulci: They separate

the right and left ventricles. The anterior interventricular
sulcus is on the sternocostal surface of the heart and lodges
anterior interventricular artery and great cardiac vein. The
posterior interventricular groove is on the diaphragmatic
surface and lodges posterior interventricular artery and
middle cardiac vein.
O2
Lung capillaries
O2 taken and
CO2 released
(Pulmonary circulation)
CO2
Left atrium
Left ventricle
Right pump
Right atrium
Right ventricle
Arterial blood
(bright red)
Venous blood
(bluish)
O2
CO2
Tissue capillaries
O2 released and CO2 taken up
(Systemic circulation)
Fig. 20.9 Heart as double pump.
Left pump
263
264
atrium flows into left ventricle through left atrioventricular

orifice. The blood is prevented from regurgitating back to
the atrium by means of left atrioventricular valve. The left
ventricle strongly contracts and propels the blood into the
ascending aorta and then into the systemic circulation.
N.B. The right ventricle is required to pump the blood
through a relatively low-resistance vascular bed, whereas
the left ventricle is required to pump the blood through a
relatively high resistance peripheral vascular bed.
The muscular wall of the left ventricle is, therefore, much
thicker than that of the right ventricle.
RIGHT ATRIUM
The right atrium is somewhat quadrilateral chamber situated
behind and to the right side of the right ventricle. It consists
of a main cavity and a small outpouching called auricle.
External Features
1. The right atrium is elongated vertically and receives
superior vena cava (SVC) at its upper end and the
inferior vena cava (IVC) at its lower end.
2. The upper anterior part is prolonged to the left to form
the right auricular appendage, the right auricle. The
margins of the auricle are notched. The right auricle
overlaps the roots of the ascending aorta completely and
infundibulum of the right ventricle partly.
3. A shallow vertical groove called sulcus terminalis
extends along the right border between the superior and
inferior vena cavae. The upper part of the sulcus contains
the sinuatrial (SA) node. Internally it corresponds to
crista terminalis.
4. The vertical right atrioventricular groove lodges the

right coronary artery and the small cardiac vein.
Internal Features (Fig. 20.10)

The interior of the right atrium is divided into two parts:
(a) main smooth posterior part the sinus venarum, and
(b) rough anterior part the atrium proper. The two parts
are separated from each other by crista terminalis. The
differences between these two parts are enumerated in Table
20.2. The interior of right atrium also presents septal wall of
the right atrium.
Septal wall of the right atrium: Developmentally it is derived
from septum primum and septum secundum. The septal
wall when viewed from within the right atrium presents the
following features:
Table 20.2 Differences between the smooth and rough
parts of the right atrium
Smooth part (sinus venarum)
Rough part (atrium proper)
Developmentally it is derived
from right horn of the sinus
venosus
Developmentally it is derived
from primitive atrium
All the venous channels except

anterior cardiac veins open into
this part (e.g., SVC, IVC,
coronary sinus, and venae
cordae minimi)
Presents series of transverse

ridges, the musculi pectinati,
which arise from the crista
terminalis and run forwards
towards the auricle. The
interior of auricle presents
reticular sponge-like network
of the muscular ridges
Superior vena cava

Crista terminalis
Auricle
Musculi pectinati
Openings of venae cordis minimi

Annulus ovalis (limbus fossa ovalis)
Fossa ovalis
Opening of coronary sinus
Right atrioventricular orifice
Valve of inferior
vena cava
Inferior vena cava
Fig. 20.10 Interior of the right atrium.
Valve of
coronary sinus
1. Fossa ovalis, a shallow oval/saucer-shaped depression in

the lower part, formed by septum primum. It represents
the site of foramen ovale in the foetus.
2. Annulus ovalis/limbus fossa ovalis, forms the distinct
upper and lateral margin of the fossa ovalis. It represents
the free edge of the septum secundum. Inferiorly the
annulus ovalis is continuous with the left end of the
valve of IVC.
3. Triangle of Koch, a triangular area bounded in front by
the base of septal leaflet of tricuspid valve, behind by
anterior margin of the opening of coronary sinus and
above by the tendon of Todaroa subendocardial ridge.
The atrioventricular node lies in this triangle.
4. Torus aorticus, an elevation in the anterosuperior part
of the septum produced due to bulging of the right
posterior (non-coronary) sinus of ascending aorta.
The sponge-like interior of right auricle prevents the free
flow of blood and thus favors the formation of thrombus. The
thrombi may dislodge during auricular fibrillation and may
cause pulmonary embolism.
Opening into the Right Atrium

There are number of openings in the right atrium. These are
as follows (Fig. 20.10):
1. Opening of SVC: The SVC opens at the upper end of the
right atrium and has no valve. It returns the blood to the
heart from the upper half of the body.
2. Opening of IVC: The IVC opens at the lower end of the
right atrium close to the interatrial septum. It is guarded
by a rudimentary non-functioning semilunar valve
called valve of the inferior vena cava/Eustachian valve.
N.B. During embryonic life, the Eustachian valve guides the

blood of IVC to the left atrium through foramen ovale. The
IVC returns the blood to the heart from the lower half of the
body. A very small projection called intervenous tubercle (of
Lower) is scarcely visible on the posterior wall of the right
atrium just below the opening of SVC. During embryonic life
it directs the blood of SVC to the right ventricle.
3. Opening of coronary sinus: The coronary sinus, which

drains most of the blood from the heart, opens into the
right atrium between the openings of IVC and right
atrioventricular orifice. It is also guarded by a
rudimentary non-functioning valve, Thebesian valve.
4. Right atrioventricular orifice (largest opening): It
communicates the right atrial chamber with the right
ventricular chamber. It lies anterior to the opening of
IVC and is guarded by the tricuspid valve.
5. Many small orifices of small veins: These are the
opening of venae cordis minimae (Thebesian veins) and
anterior cardiac veins.
RIGHT VENTRICLE
The right ventricle is the thick-walled triangular chamber of
the heart which communicates with the right atrium through
right atrioventricular orifice and with the pulmonary trunk
through pulmonary orifice.
External Features
1. It forms the most of sternocostal surface and small part
of the diaphragmatic surface of the heart. It also forms
the inferior border.
2. It is separated from the right atrium by a more or less
vertical anterior part of the coronary sulcus/
atrioventricular groove.
Pulmonary value
Infundibulum
Supraventricular crest
Septal papillary
muscle
Right atrial
chamber
Moderator band
Anterior cusp
of AV orifice
Anterior papillary
muscle
Posterior cusp
of AV orifice
Posterior papillary
muscle
Septal cusp
of AV orifice
Fig. 20.11 Main features in the interior of right ventricle (AV = atrioventricular).
265
266
Table 20.3 Differences of inflowing and outflowing parts of

the right ventricle
Inflowing lower part
Outflowing upper part
It develops from primitive

ventricle
It develops from bulbus cordis
It is large in size and lies

below the supraventricular
crest
It is small in size and lies above

the supraventricular crest
It is rough due to presence of

the muscular ridgesthe
trabeculae carneae. It forms
most of the right ventricular
chamber
It is smooth and forms upper 1

inch conical part of the right
ventricular chamberthe
infundibulum, which gives rise
to pulmonary trunk

1. The interior of right ventricle consists of two parts: (a) a
large, lower rough inflowing part, and (b) a small upper
outflowing part, the infundibulum. The two parts are
separated from each other by a muscular ridge, the
supraventricular crest (infundibuloventricular crest).
The differences of two parts are enumerated in Table
20.3.
2. The cavity of right ventricle is flattened by the forward
bulge of the interventricular septum. In transverse
section it is crescent shaped (Fig. 20.13).
3. The wall of the right ventricle is thinner than that of the
left ventricle (ratio 1:3).
Trabeculae Carneae of Right Ventricular Chamber

These are muscular projections which give the ventricular
chamber a sponge-like appearance.
Types of Trabeculae Carneae
Trabeculae carneae are of three types: (a) ridges (fixed
elevations), (b) bridges (only ends are fixed, the central part
is free), and (c) pillars (base is fixed to ventricular wall and
apex is free).
Papillary muscles
These represent the pillars of trabeculae carneae. The
papillary muscles project inwards. Their bases are attached
to the ventricular wall and their apices are connected by
thread-like fibrous cords (the chordae tendinae) to the cusps
of the tricuspid valve.
There are three papillary muscles in the right ventricle:
(a) anterior, (b) posterior (inferior), and (c) septal. The
anterior is largest, posterior is small, and septal is usually
divided into two or three nipples. The papillary muscles of
right ventricle are attached to the cusps of the tricuspid valve.
Moderator band (septomarginal trabeculum)

It is thick muscular ridge extending from ventricular septum
to the base of the anterior papillary muscle, across the
ventricular cavity. It conveys the right branch of the
atrioventricular bundle (bundle of His), a part of conducting
system of the heart. It prevents the over distension of right
ventricle.
LEFT ATRIUM
External Features
1. It is a thin-walled quadrangular chamber situated
posteriorly behind and to the left side of right atrium. It
forms greater part (left 2/3rd) of the base of the heart.
2. Its upper end is prolonged anteriorly to form the left
auricle, which overlaps the infundibulum of right
ventricle.
3. Behind the left atrium lies: (a) oblique sinus of serous
pericardium and (b) fibrous pericardium, which
separates it from the esophagus.
Internal Features
1. The interior of left atrium is smooth, but the left auricle
possesses muscular ridges in the form of reticulum.
2. The anterior wall of left atrial cavity presents fossa
lunata, which corresponds to the fossa ovalis of the right
atrium.
Openings in the Left Atrium

Openings in the left atrium are as follows:
1. Openings of four pulmonary veins in its posterior wall,
two on each side. They have no valves.
2. Number of small openings of venae cordis minimae.
3. Left atrioventricular orifice. It is guarded by the mitral
valve.
LEFT VENTRICLE
The left ventricle is thick-walled triangular chamber of the
heart which communicates with the left atrium through left
atrioventricular orifice and with the ascending aorta through
aortic orifice. The walls of left ventricle are three times thicker
than that of the right ventricle.
External Features
The left ventricle forms the (a) apex of the heart, (b) small
part of the sternocostal surface, (c) most of the (left 2/3rd)
diaphragmatic surface, and (d) most of the left border of the
heart.
Ascending aorta
Aortic valve
Aortic vestibule
Left atrial chamber

Anterior cusp
of mitral valve
Anterior papillary
muscle
Posterior cusp
of mitral valve
Posterior papillary
muscle
Fig. 20.12 Main features in the interior of left ventricle.
Sternocostal surface
2 3 rd
1 3 rd
Pulmonary
orifice
Anterior papillary
muscle
Septal papillary
muscle
Aortic orifice
Anterior papillary
muscle
Bicuspid orifice
Tricuspid orifice
Posterior papillary
muscle
Posterior/Inferior
papillary muscle
1 3 rd
2 3 rd
Diaphragmatic surface
Fig. 20.13 Transverse section across the ventricles of the heart. Note the difference in the thickness of the wall and shape
of the right and left ventricular cavities.

The interior of the left ventricle is divided into two parts:
(a) a large lower rough inflowing part, and (b) a small upper
smooth outflowing partthe aortic vestibule.
The differences between these two parts are enumerated

in Table 20.4.
The cavity of the left ventricle is circular in cross section
because the interventricular septum bulges into the right
ventricle.
267
268
Table 20.4 Differences between the inflowing and outflowing parts of the left ventricle
Inflowing part
Outflowing part
It develops from primitive

ventricle
It develops from bulbus cordis
It lies below the aortic

vestibule
It lies between the membranous

part of the interventricular
septum and anterior cusp of the
mitral valve
It is rough due to presence

of trabeculae carneae and
forms most of the left
ventricular chamber
It is smooth and forms smooth

small upper partthe aortic
vestibule, which gives rise to the
ascending aorta
Trabeculae Carneae of Left Ventricle

The trabeculae carneae of the left ventricle are similar to
those of the right ventricle but are well developed and present
two large papillary muscles (anterior and posterior) and no
moderator band. The papillary muscles of the left ventricle
are attached to the cusps of the mitral valve by chordae
tendinae.
Openings in the Left Ventricle
The openings in the left ventricle are as follows:
1. Left atrioventricular orifice.
2. Aortic orifice.
Table 20.5 Differences between the right and left ventricles

Right ventricle
Left ventricle
Receives deoxygenated blood

from right atrium and pumps
it to the lungs through
pulmonary trunk
Receives oxygenated blood

from left atrium and pumps it
to the whole body through
aorta
Wall of right ventricle is

thinner than that of left
ventricle (ratio 1:3)
Wall of left ventricle is thicker

than that of right ventricle
(ratio 3:1)
Possesses three papillary

muscles (anterior, posterior,
and septal)
Possesses two papillary

muscles (anterior and
posterior)
Moderator band present
Moderator band absent
Cavity of right ventricle is

crescentic in shape in cross
section
Cavity of left ventricle is

circular in shape in cross
section
ATRIOVENTRICULAR VALVES
The right and left atria communicate with the right and left
ventricles through right and left atrioventricular orifices,
respectively. The right and left atrioventricular orifices are
guarded by the right and left atrioventricular valves
respectively.
The main features as seen in transverse section through

the ventricles are shown in Fig. 20.13.
The main differences between the right and left ventricle
are listed in Table 20.5.
VALVES OF THE HEART (Fig. 20.14)
There are two pairs of valves in the heart: (a) a pair of

atrioventricular valves, and (b) a pair of semilunar valves.
The valves prevent regurgitation of the blood.
Right atrioventricular valve (also known as tricuspid

valve): As the name indicates it has three cuspsanterior,
posterior and septal, which lie against the three walls of
the ventricle. The tricuspid valve can admit the tips of
three fingers.
Left atrioventricular valve (also known as bicuspid/
mitral valve). As the name indicates it has two cuspsa
larger anterior/aortic cusp and a smaller posterior cusp.
The mitral/bicuspid valve can admit the tips of two
fingers.
Pulmonary valve
Semilunar
valves
Aortic valve
Bicuspid/mitral valve
(Left atrioventricular valve)
Fig. 20.14 The valves of the heart.
Tricuspid valve
(Right atrioventricular valve)
Structure
SEMILUNAR VALVES (Fig. 20.16)
The atrioventricular valves are made up of two components

(Fig. 20.15):
The right and left ventricles pump out blood through

pulmonary and aortic orifices, respectively. Each of these
orifices is guarded by three semilunar cusps hence they are
called semilunar valves. Both aortic and pulmonary valves
are similar to each other in structure and functions.
Each valve has three cusps which are attached directly
to the wall of aorta/pulmonary trunk. (Note that they do
not have fibrous ring similar to tricuspid and mitral
valves.)
The cusps form small pockets with their mouths directed
upwards towards the lumen of great vessels. Each cusp has a
fibrous nodule at the midpoint of its free edge. On each side
of the nodule the thickened crescentic edge is called lunule,
which extends up to the base. When the valve is closed, the
nodules meet in the center.
The cusps of semilunar valves are open and stretched
during ventricular systole and closed during ventricular
diastole to prevent regurgitation of the blood into the
ventricle.
1. A fibrous ring.
2. Cusps.
The fibrous rings surround the orifice. The cusps are
formed by the fold of the endocardium enclosing some
connective tissue within it. Each cusp has an attached and
free margin and atrial and ventricular surfaces. The atrial
surfaces are smooth. The ventricular surfaces and free
margins are rough and provide attachment to the chordae
tendinae. As discussed earlier, the chordae tendinae
connect the apices of papillary muscles with margins and
ventricular surfaces of the cusps. The chordae tendinae of
each papillary muscle are attached to the contiguous halves
of the two cusps.
The valves are closed during ventricular systole. The
papillary muscles shorten and chordae tendinae are pulled
upon to prevent the eversion of the cusps of tricuspid valve
due to increased intraventricular pressure.
N.B.
The nutrition to the fibrous ring and basal one-third of
cusps is provided by the blood vessels.
The nutrition to the distal two-third of the cusps is
provided directly by the blood within the chambers of the
heart.
The cusps of mitral valve are smaller but thicker than
those of tricuspid valve.
Role of papillary muscle in acute cardiac failure: The
papillary muscles prevent the prolapse of atrio-ventricular
valves into the atria during ventricular systole. The rupture of
a papillary muscle, following an adjacent myocardial
infarction, will allow the prolapse of the affected cusp to
occur into the atrium at each systole. This will consequently
lead to acute cardiac failure.
N.B.
No chordae tendinae or papillary muscles are associated
with semilunar valves. The attachment of the sides of
cusps to the atrial wall prevents regurgitation of blood.
Opposite to the cusps, the roots of pulmonary trunk and
ascending aorta present three dilatations called sinuses.
The blood in these sinuses prevents the cusps from
sticking to the wall of great vessels. The anterior aortic
sinus gives origin to the right coronary artery and left
posterior aortic sinus gives origin to the left coronary
artery.
Positions of Cusps in the Pulmonary and Aortic Valves

The positions of cusps of pulmonary valves are: (a) right
anterior, (b) left anterior, and (c) posterior.
The positions of cusps of aortic valve are just opposite to
those of the pulmonary valve. They are: (a) right posterior,
(b) left posterior, and (c) anterior.
Fibrous ring
Cusps
Chordae
tendinae
Papillary
muscles
Fig. 20.15 Right atrioventricular (tricuspid) valve spread out to show its structure.
269
270
Ascending aorta
Nodule
Nodule
Left coronary artery
Right coronary
artery
Aortic sinus
Cusp
Cusp
Lunule
Fig. 20.16 Structure of aortic valve. Note that it consists of three semilunar cusps. Each cusp has a fibrous nodule at the
midpoint of its free edge. The thickened crescentic edge on each side of nodule is the lunule (L. luna = moon). Inset figure
on right side shows aortic sinus and origin of coronary artery.
The aortic sinuses are also named accordingly, i.e., right

posterior aortic sinus, left posterior aortic sinus, and anterior
aortic sinus. The right coronary artery arises from anterior
aortic sinus and left coronary from left posterior aortic sinus.
Since no coronary artery arises from right posterior aortic
sinus, it is referred to by some anatomists as non-coronary
sinus.
N.B. Embryologically, pulmonary valve has anterior, right
and left cusps whereas aortic valve has posterior, right and
left cusps (Fig. 20.17). Thus the left coronary artery arises
from the left aortic sinus, the right coronary artery from the
right aortic sinus and no artery arises from the posterior
aortic sinus (non-coronary sinus).
In aortic and pulmonary stenosis the murmur is heard

during systole and in insufficiency of these valves they
are heard during diastole.
In stenosis of mitral and tricuspid valves, the murmurs
are heard during diastole and in their insufficiency
during systole.
Mitral stenosis (narrowing of mitral orifice): It is most
common in young age. Usually there is history of rheumatic
fever in the childhood in these cases. This leads to rise in
the left atrial pressure and enlargement of left atrium
which may press on the esophagus.
Clinically features of mitral stenosis will be as follows:
1. Shortness of breath (dyspnea).
2. Dysphagia (difficulty in swallowing).
3. Hoarseness of voice (Ortners syndrome).
Murmurs: The abnormal heart sounds are called
murmurs. They are produced due to regurgitation of blood
heard when the valves are either stenosed or when the
valves are not closed properly (leading to regurgitation).
Aortic valve
P
L
R
Tricuspid stenosis: In tricuspid stenosis blood flow from

right atrium to right ventricle is reduced. The elevation of
right atrial pressure leads to systemic venous congestion
and right heart failure.
Aortic stenosis: In aortic stenosis there accumulation of
blood in left ventricle, causing its dilatation and
hypertrophy. There is low cardiac output which may
manifest as syncope (fainting) on exertion.
Pulmonary stenosis: It is almost always congenital,
usually a part of Fallots tetralogy. It leads to hypertrophy
of right ventricle.
Right coronary
artery
Pulmonary valve
R
A
Fig. 20.17 Embryological position of cusps in the pulmonary

and aortic valves (P = posterior, A = anterior, R = right, L =
left).
HEART SOUNDS
The two sounds are produced by the heartthe first heart
sound is produced by the closure of the atrioventricular
(tricuspid and mitral) valves and the second heart sound is
produced by the closure of semilunar (aortic and pulmonary)
valves. These sounds are heard by the clinician by auscultation
with stethoscope. The first and second heart sounds are

heard as LUB and DUB, respectively.
SURFACE MARKINGS OF THE CARDIAC VALVES

AND AUSCULTATORY AREAS (Fig. 20.18)
The pulmonary, aortic, mitral, and tricuspid valves are

located posterior to the sternum on an oblique line joining
the 3rd left costal cartilage to the 6th right costal cartilage.
The position of valves on the surface of the chest and sites
of their auscultatory areas are given in Table 20.6 and shown
in Figure 20.19.
The sounds produced by closure of valves of the heart are

best heard not directly over the location of valve but at areas
situated some distance away from the valve in the direction
of blood flow through them.
N.B. Blood tends to carry the sound in the direction of its

flow, consequently auscultatory area is located superficial to
the vessel or chamber through which the blood passes and
is in direct line with the valve orifice.
Table 20.6 Surface markings of the cardiac valves and the sites of their auscultatory areas
Valve
Surface marking
Site of auscultator area
Pulmonary valve
A horizontal line (2.5 cm long) behind the medial end left 3rd
costal cartilage and adjoining part of the sternum
Second left intercostal space near the sternum
Aortic valve
A lightly oblique line (2.5 cm long) behind the left half of the
sternum opposite the 3rd intercostal space
Second right intercostal space near the sternum
Mitral valve
An oblique line (3 cm long) behind the left half of the

sternum opposite the left 4th costal cartilage
Left 5th intercostal space 3 inches (9 cm) from

midline, i.e., over apex beat
Tricuspid valve
Nearly vertical oblique line (4 cm long) behind the right half

of the sternum opposite the 4th and 5th intercostal spaces
Right half of the lower end of the body of the

sternum
Pulmonary area
Aortic area
P
A
T
Mitral area
Tricuspid area
Tricuspid area
Fig. 20.18 Surface projection of cardiac valves and sites of their auscultatory areas (P = pulmonary valve, A = aortic valve,
T = tricuspid valve, M = mitral valve).
271
272
Fibrous ring around

the pulmonary valve
Trigonum fibrosum sinistrum
Tendon of
infundibulum
Fibrous ring around

the aortic valve
Trigonum fibrosum
dextrum
Tricuspid valve
Mitral valve
Membranous part of
interventricular septum
Fig. 20.19 Skeleton of the heart.
SKELETON OF THE HEART (Fig. 20.19)

The so called skeleton of the heart is composed of fibrous
tissue and forms the central support of the heart. It consists
of fibrous rings that surround the atrioventricular,
pulmonary, and aortic orifices. These rings provide circular
form and rigidity to the atrioventricular orifices and roots of
the aorta and pulmonary trunk. They also provide
attachment to the valves and prevent dilatation of these
orifices. The cardiac valves are firmly attached to this
skeleton. The cardiac skeleton along with membranous part
of interventricular septum also provides attachments to the
cardiac muscle fibres.
The fibrous rings around the atrioventricular orifices
separate the muscle fibres of atria from those of the ventricles,
but provide attachment to these fibres. Thus there is no
muscular continuity between the atria and ventricles, except
for the atria ventricular bundle (bundle of His) of the
conducting system.
Functional significance:
1. The skeleton of the heart allows cardiac muscle to
contract against the rigid base.
2. The fibrous rings support the bases of the cusps of the
valves and prevent the valves from stretching and
becoming incompetent. The aortic ring is the strongest.
N.B.
The atrioventricular fibrous rings (AV rings) form the
figure of 8.
The large mass of fibrous tissue between AV rings and
aortic ring is called trigonum fibrosum dextrum. In some
mammals such as sheep, elephant, etc. a bonethe os
cordis develops in it.
The small mass of fibrous tissue between the fibrous rings
around semilunar valves is called trigonum fibrosum
sinistrum.
The tendon of infundibulum binds the posterior surface
of the infundibulum to the aortic ring.
CONDUCTING SYSTEM OF THE HEART (Fig. 20.20)

COMPONENTS
The conducting system of the heart is made up of specialized
cardiac muscle fibres (not nervous tissue) and is responsible
for initiation and conduction of cardiac impulse.
The conducting system of the heart consists of the
following five components:
1.
2.
3.
4.
5.
Sinuatrial node (SA node).

Atrioventricular node (AV node).
Atrioventricular bundle (of His).
Right and left branches of bundle of His.
Subendocardial Purkinje fibres.
Sinuatrial node (SA node or node of Keith Flack): It is a

small horseshoe-shaped mass having specialized myocardial
fibres, situated in the wall of the right atrium in the upper
part of sulcus terminalis just below the opening of superior
vena cava.
SVC
SA node
Right
atrium
AV bundle
(of His)
AV node
Left branch of
AV bundle
Purkinje
f ibers
IVC
Right branch of
AV bundle
Moderator band
Fig. 20.20 Conducting system of the heart (SA = sinuatrial,

AV = atrioventricular).
It is known as pacemaker of the heart because it generates

impulses (about 70/minute) and initiates the contraction of
cardiac muscle producing heart beat.
Atrioventricular node (AV node/node of Tawara): It is
smaller than the SA node and is located in the lower part of
the atrial septum, just above the attachment of septal cusp of
the tricuspid valve/opening of the coronary sinus. It conducts
the cardiac impulse to the ventricle by the atrioventricular
bundle. The AV node is capable of generating impulses at the
rate of about 60/min. The speed of conduction of cardiac
impulse (about 0.11 sec) provides sufficient time to the atria
to empty their blood into the ventricle before ventricles start
contracting.
Atrioventricular bundle (of His): It begins from AV node,
crosses the AV ring and runs along the inferior part of the
membranous part of the interventricular septum where it
divides into the left and right branches.
N.B. Since the skeleton (fibrous framework) of the heart
separates the muscles of atria from the muscles of the
ventricles, the bundle of His is the only means of conducting
impulses from the atria to the ventricles.
Right and left branches of the bundle (of His): The right
branch passes down the right side of the interventricular
septum and then becomes subendocardial on the right side
of the septum. A large part of it continues in the septomarginal
trabeculum (moderator band) to reach the anterior papillary
muscle and anterior wall of the ventricle. Its Purkinje fibres
then spread out beneath the endocardium.
The left branch descends on the left side of the ventricular
septum, divides into Purkinje fibres which are distributed to
the septum and left ventricle.
Purkinje fibres: They are the terminal branches of right and
left branches of the bundle of His and spread subendocardially
over the septum and the rest of the ventricular wall.
The conducting system and mode of contraction of
cardiac muscle is summarized as follows:
The SA node (a spontaneous source of cardiac impulse)
initiates an impulse which rapidly spreads to the muscle fibres
of the atria, making them to contract. The AV node picks up
the cardiac impulse from atria and conducts it through
atrioventricular bundle and its branches to the papillary
muscles and the walls of the ventricles. The papillary muscles
contract first, to tighten the chordae tendinae and then the
contraction of ventricular muscle occurs.
Arterial Supply of the Conducting System

The whole of the conducting system of the heart is supplied
by the right coronary artery except a part of the left branch
of the AV bundle which is supplied by the left coronary
artery.
Conducting system defects: The defect/damage of
conducting system causes cardiac arrhythmias.
The SA node is the spontaneous source of generation of
cardiac impulses. The AV node picks up these impulses
from atria and sends them to the ventricles through AV
bundle, the only means through which impulses can spread
from the atria to ventricles.
If the AV bundle fails to conduct normal impulses, there
occurs alteration in the rhythmic contraction of the ventricles
(arrhythmias). If complete bundle block occurs there is
complete dissociation in the rate of contraction of atria and
ventricles. The commonest cause of defective conduction
through AV bundle is atherosclerosis of the coronary arteries
which leads to diminished blood supply to the conducting
system.
N.B. The rapid pulse is called tachycardia, the slow

pulse is called bradycardia whereas irregular pulse is
called arrhythmia.
ARTERIAL SUPPLY OF THE HEART (Fig. 20.21)

The heart is mostly supplied by the two coronary arteries,
which arise from the ascending aorta immediately above the
aortic valve.
The coronary arteries and their branches run on the
surface of heart lying within the subpericardial fibrofatty
tissue.
N.B.
Coronary arteries are vasa vasorum of the ascending
aorta.
Anatomically coronary arteries are not end-arteries but
functionally they behave like end-arteries.
RIGHT CORONARY ARTERY

Origin
The right coronary artery arises from the anterior aortic sinus
of the ascending aorta, immediately above the aortic valve.
Course
After arising from the ascending aorta, the right coronary
artery first runs forwards between the pulmonary trunk and
the right auricle, and then it descends almost vertically in the
right atrioventricular groove (right anterior coronary sulcus)
up to the junction of the right and the inferior borders of the
heart. At the inferior border of the heart, it turns posteriorly
and runs in the posterior atrioventricular groove (right
posterior coronary sulcus) up to the posterior interventricular
273
Table 20.7 Major branches of the right and left coronary

arteries
Right coronary artery
Right marginal artery
Anterior interventricular artery
Posterior interventricular artery Circumflex artery

Sinuatrial nodal artery
Diagonal artery
2. Circumflex artery: It gives a left marginal artery that

supplies the left margin of the left ventricle up to the
apex of the heart.
3. Diagonal artery: It may arise directly from the trunk of
the left coronary artery.
4. Conus artery: It supplies the pulmonary conus.
5. Atrial branches: They supply the left atrium.
The major branches of the right and left coronary arteries
are summarized in Table 20.7.
VARIATIONS IN THE CORONARY ARTERIES/

CORONARY DOMINANCE
The origin, course, and distribution of the posterior
interventricular artery are variable.
In right coronary dominance, the posterior interventricular
artery is a branch of the right coronary artery. It is found in
90% of the individuals.
In left coronary dominance, the posterior interventricular
artery arises from circumflex branch of the left coronary
artery. It is found in 10% of the individuals.
ANASTOMOSES OF THE CORONARY ARTERIES

Anastomoses exist between the terminal branches of the
coronary arteries at the arteriolar level (collateral circulation).
The time factor in occlusion of an artery is very important. If
occlusion occurs slowly, there is time for the healthy arterioles
to open up and collateral circulation is established, i.e., the
anastomoses become functional. But if sudden occlusion of
one of the large branches (coronary artery) occurs, the
arterioles do not get time to open up to provide collateral
circulation.
Angina pectoris: If the coronary arteries are narrowed,
the blood supply to the cardiac muscles is reduced. As a
result, on exertion, the patient feels moderately severe
pain in the region of left precordium that may last as long
as 20 minutes. The pain is often referred to the left shoulder
and medial side of the arm and forearm.
In angina pectoris pain occurs on exertion and relieved by
rest. This is because the coronary arteries are so narrowed
that the ischemia of cardiac muscle occurs only on
exertion.
Myocardial infarction (MI): A sudden block of one of the

larger branches of either coronary artery usually leads to
myocardial ischemia followed by the myocardial necrosis
(myocardial infarction). The part of heart suffering from MI
stops functioning and often causes death. This condition
is termed heart attack or coronary attack.
The clinical features of MI are as follows:
1. A sensation of pressure/sinking and pain in the chest
that lasts longer than 30 minutes.
2. Nausea or vomiting, sweating, shortness of breath, and
tachycardia.
3. Pain radiates to the medial side of the arm, forearm,
and hand. Sometimes, it may be referred to jaw or neck.
Sites of coronary artery occlusion: The three most
common sites of the coronary artery occlusion are as under:
(a) Anterior interventricular artery/left anterior descending
(LAD) artery = 4050%.
(b) Right coronary artery = 3040%.
(c) Circumflex branch of the left coronary artery = 1520%.
Note:
The MI mostly occurs at rest whereas angina occurs on
exertion.
Anterior interventricular artery/left anterior descending
(LAD) artery is most commonly blocked.
Coronary angiography: The coronary angiography is a
radiological procedure to visualize the coronary arteries
after injecting contrast medium in their lumen (Fig. 20.22).
The coronary angiography is useful in localizing the sites
of the blocks in the coronary arteries.
Coronary bypass surgery: The coronary bypass surgery
has become common in recent times in patients with
unstable/severe angina due to obstruction of the coronary
artery. A segment of a vein or an artery is connected to
the ascending aorta (or to the proximal part of the
coronary artery) and then to coronary artery distal to the
obstruction (Fig. 20.23). A coronary bypass graft shunts
blood from the aorta to coronary artery distal to the
blockage to increase the circulation.
N.B.
The great saphenous vein is commonly used for
grafting because (a) it is easily dissected, (b) it has
diameter equal to or greater than that of coronary
artery, and (c) it provides lengthy portions with a
minimum occurrence of valves or branching.
The use of left internal mammary artery graft (LIMA
graft) and radial artery graft (RA graft) have also
become increasingly common.
Coronary angioplasty: In this process the cardiologists
pass a small catheter with a small inflatable balloon
attached to its tip into the obstructed coronary artery. As the
catheter reaches the obstruction, the balloon in inflated. As
a result atherosclerotic plaque is flattened against the
vessel wall and the vessel is stretched to increase the
lumen. Consequently the blood flow is increased.
Sometimes transluminal instruments with rotating blades
and lasers are used to cut the clot. After the artery is dilated,
an intravascular stent is introduced to maintain the
dilatation.
275
Great cardiac vein

Anterior cardiac
veins
Coronary sinus
Oblique vein of
left atrium
Left marginal vein
Small cardiac vein

Middle cardiac vein
Right marginal vein
SVC
Left atrium
Great cardiac vein
Oblique vein of
left atrium
Left marginal
vein
Great cardiac vein
Posterior vein
of left ventricle
Coronary sinus
IVC
Right atrium
Middle cardiac vein
Small cardiac vein
Right marginal vein
Oblique vein of
left atrium
Coronary sinus
Left marginal vein
Posterior vein
of left ventricle
Small cardiac
vein
Great cardiac vein

Middle cardiac vein
Right marginal
vein
Fig. 20.24 Veins of the heart: A, anterior view of the heart showing cardiac veins; B, posteroinferior view of the heart showing
the cardiac veins; C, tributaries of the coronary sinus viewed form the front.
277
278
6. Right marginal vein: It accompanies the marginal

branch of the right coronary artery and joins the small
cardiac vein or drains directly into the right atrium.
7. Left marginal vein: It accompanies the marginal branch
of the left coronary artery and drains into the coronary
sinus.
Anterior cardiac veins: These are series of small veins (3 or 4)
which run parallel to each other across the surface of right
ventricle to open into the right atrium.
Venae cordis minimae (Thebesian veins): These are extremely
small veins in the walls of all the four chambers of the heart.
They open directly into the respective chambers. They are
most numerous in the right atrium.
LYMPHATIC DRAINAGE OF THE HEART

The lymphatics of the heart accompany the coronary arteries,
emerge from the fibrous pericardium along with the
ascending aorta and pulmonary trunk in the form of two
trunks. The right trunk drains into brachiocephalic nodes
and left trunk drains into tracheobronchial nodes (at the
bifurcation of the aorta).
NERVE SUPPLY OF THE HEART

The heart is supplied by the sympathetic and parasympathetic
fibres via the superficial and deep cardiac plexuses formed
by the parasympathetic and sympathetic fibres.
The parasympathetic fibres are derived from vagus

nerves. They are cardioinhibitory; hence their stimulation
causes slowing of the heart rate and constriction of the
coronary arteries.
The sympathetic fibres are derived from upper 35
thoracic spinal segments. They are cardioacceleratory, hence
their stimulation increase the heart rate and causes the
dilatation of the coronary arteries. The sympathetic fibres
also cause dilatation of the coronary arteries.
A brief account of formation and distribution of cardiac
plexuses is given in the following text.
CARDIAC PLEXUSES
Superficial Cardiac Plexus
The superficial cardiac plexus (Fig. 20.25) lies below the
arch of aorta in front of the bifurcation of pulmonary trunk,
just to the right of ligamentum arteriosum. The cardiac
ganglion (of Wrisberg) lies close to the ligamentum
arteriosum.
It is formed by the:
(a) superior cervical cardiac branch of left cervical
sympathetic trunk, and
(b) inferior cervical cardiac branch of left vagus nerve.
Distribution
The superficial cardiac plexus gives branches to (a) deep
cardiac plexus, (b) right coronary artery, and (c) left anterior
pulmonary plexus.
Left cervical sympathetic chain
Left vagus nerve

Superior cervical cardiac branch
of left cervical sympathetic chain
Inferior cervical cardiac
branch of left vagus nerve
Arch of aorta
Ligamentum arteriosum
Superficial cardiac
plexus
Cardiac ganglion
Bifurcation of
pulmonary trunk
Fig. 20.25 Superficial cardiac plexus.
Superior cervical cardiac branch of

left sympathetic chain
Superficial cardiac plexus
Superior cervical sympathetic
ganglion
Middle cervical sympathetic
ganglion
Left vagus
nerve
Right vagus
nerve
Stellate ganglion
Inferior cervical cardiac

branch of left vagus
nerve to superficial
cardiac plexus
T2 ganglion
T3 ganglion
T4 ganglion
T5 ganglion
Deep cardiac
plexus
Deep cardiac
plexus
Fig. 20.26 Deep cardiac plexus: A, parasympathetic contribution; B, sympathetic contribution.
Deep Cardiac Plexus (Fig. 20.26)

The deep cardiac plexus lies in front of the bifurcation of the
trachea, behind the arch of the aorta.
It is formed by:
(a) all the cardiac branches derived from three cervical and
upper 4 or 5 thoracic ganglia of the sympathetic chains
except the superior cervical cardiac branch of left cervical
sympathetic chain, and
(b) all the cardiac branches of vagus and recurrent laryngeal
nerves except the inferior cervical cardiac branch of the
left vagus nerve.
Distribution
The right and left halves of the plexus distributes branches to
(a) corresponding coronary arteries and pulmonary plexus,
and (b) separate branches to the atria.
thoracic sympathetic ganglia and follow the usual

somatosensory pathway to the central nervous system. The
pain fibres pass from thoracic ganglia to the spinal nerves via
white rami communicantes. The cell bodies of the first order
sensory neurons are located in the dorsal root ganglia of T1
T5 spinal nerves. Hence cardiac pain is referred mainly in the
area of distribution of these nerves, i.e., pectoral region and
medial aspect of the arm and forearm.
N.B. Sometimes cardiac pain is referred to the neck and
mandible. It is because of the connection of sympathetic
fibres with the cervical nerves.
Pathways for Cardiovascular Reflexes

The afferent fibres from heart subserving the cardiovascular
reflexes pass by the parasympathetic fibres of vagal nerves to
the reticular formation.
PAIN AND REFLEX PATHWAYS OF THE HEART

ACTION OF THE HEART
Pain Pathways
The sensations of pain arising due to the ischemia of the
heart pass through the sympathetic fibres to reach the upper
five thoracic spinal segments (T1T5) through cervical and
The heart is actually a double muscular pump. The right side

pumps blood to the lungs and left side pumps blood to all
the parts of the body. Each pump is made up of an atrium
and a ventricle.
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280
Cardiac cycle: The contraction of heart followed by

relaxation is one cardiac cycle. The contraction of the heart
is termed systole and relaxation is known as diastole. During
cardiac cycle series of changes take place as it fills with blood
and empties the same. Normally the heart beats 7090 times
per minute in adults and 130150 times per minute in the
newborn baby.
Tachycardia and bradycardia: The increased heart rate
(rapid pulse) is called tachycardia and decreased heart
rate (slow pulse) is called bradycardia.
Arrhythmia: The irregular heart rate (irregular pulse) is
called arrhythmia.
282
Answers
1. It is cardiac pain which occurs on exertion due to
the narrowing of the coronary artery/arteries or
their major branches. The pain is relieved by
resting.
2. The afferent pain fibres from heart reach the upper
four or five thoracic spinal segments through the
cardiac branches of the sympathetic trunks usually
on the left side. Pain is referred in the left
pericardiumT4 and T3 dermatomes and medial
side of the arm (T2 dermatome) and medial side of
the forearm (T1 dermatome).
3. Right and left coronary arteries. The right coronary
artery arises from anterior aortic sinus at the root
of ascending aorta while left coronary artery arises
from left posterior aortic sinus at the root of
ascending aorta.
4. The differences between angina pectoris and

myocardial infarction are follows:
Angina pectoris
Myocardial infarction (MI)

(heart attack)
Occurs due to narrowing

of the coronary artery/
arteries causing myocardial
ischemia
Occurs due to complete

block of the coronary
artery/arteries causing
myocardial ischemia that
induces myocardial
necrosis
Occurs on exertion and is

relieved on rest
Occurs on rest
Sensation of pressure or
burning in chest that may
last as long as 20 minutes
Sensation of pressure or
burning in the chest that
lasts longer than 30
minutes
CHAPTER
21
Superior Vena Cava,

Aorta, Pulmonary
Trunk, and Thymus
The knowledge of anatomy of superior vena cava, aorta, and

pulmonary trunk is clinically important because of their
involvement in various disease processes such as obstruction
of superior vena cava, aortic aneurysm, pulmonary
embolism, etc.
Relations (Figs 21.1B and 21.2)

Anterior:
1. Right internal thoracic vessels.
2. Margin of right lung and pleura.
3. Chest wall
SUPERIOR VENA CAVA (Fig. 21.1)

The superior vena cava (SVC) is about 7 cm long and 1.25 cm
in diameter. It lies in the superior and middle mediastina. Its
extrapericardial part lies in the superior mediastinum and its
intrapericardial part lies in the middle mediastinum. It
collects blood from the upper half of the body (i.e., head and
neck, upper limbs, thoracic wall, and upper abdomen) and
drains it into the right atrium. Depending upon the site of
obstruction, different collateral pathways develop. In
mediastinal syndrome, the signs of obstruction of superior
vena cava appear first.
Formation, Course, and Termination

The superior vena cava is formed at the lower border of the
right 1st costal cartilage by the union of right and left
brachiocephalic (innominate) veins. It passes vertically
downwards behind the right border of the sternum and
pierces the pericardium at the level of the right 2nd costal
cartilage, and opens/terminates into the upper part of the
right atrium at the lower border of the right 3rd costal
cartilage. It has no valves in its lumen because gravity
facilitates the blood flow in it.
Subdivisions
The superior vena cava is subdivided into the following two
parts:
1. Extrapericardial part (in superior mediastinum).
2. Intrapericardial part (in middle mediastinum).
Posterior:
1. Trachea (posteromedial).
2. Right pulmonary artery and right bronchus.
To the left:
1. Ascending aorta (anteromedial).
2. Brachiocephalic artery.
To the right:
1. Right phrenic nerve and pericardiophrenic
vessels.
2. Right lung and pleura.
Tributaries
1. Right and left brachiocephalic veins.
2. Azygos vein, which arches over the root of the right lung
and opens into SVC just before it pierces fibrous
pericardium.
3. Mediastinal and pericardial veins.
Brachiocephalic Veins
There are two brachiocephalic veins: (a) right and (b) left.
Each of them is formed behind the sternoclavicular joint by
the union of corresponding internal jugular and subclavian
veins. They unite to form SVC. Both are devoid of valves.
Differences between the right and left brachiocephalic veins
are enumerated in Table 21.1.
284
Right internal jugular vein
Left internal jugular vein

Clavicle
Right subclavian vein
Left subclavian vein
CC1
CC2
Superior vena cava
Azygos vein
CC3
Right
atrium
Right and left recurrent

laryngeal nerves
Left vagus nerve
Right vagus nerve

Right phrenic nerve
Left phrenic nerve
Left internal thoracic

artery
Right internal
thoracic artery
Pericardiophrenic
artery
Fig. 21.1 Superior vena cava: A, formation, course, and termination; B, relations (CC = costal cartilage).
Table 21.1 Differences between right and left brachiocephalic veins

Length
Short (2.5 cm)
Long (6 cm)
Course
Vertical (runs vertically downwards from right

sternoclavicular joint to the lower margin of the right
1st costal cartilage)
Oblique (runs obliquely across the superior

mediastinum from left sternoclavicular joint to the
lower margin of the right 1st costal cartilage)
Tributaries
Right vertebral vein

Right internal thoracic vein
Right inferior thyroid vein
First right posterior intercostal vein
Left vertebral vein

Left internal thoracic vein
Left inferior thyroid vein
First left posterior intercostal vein

Chest wall
A
Right internal
thoracic vessels
Margin of right
lung and pleura
Superior vena cava
Ascending
aorta
L
P
Right phrenic nerve

Pericardiophrenic
vessels
Right pulmonary
artery
Right bronchus
Trachea
Fig. 21.2 Relations of superior vena cava as seen in the cross section of the thorax.
Obstruction of SVC and development of collateral
pathways:
The SVC may be obstructed (compressed) at two sites:
(a) above the opening of azygos vein (i.e., in superior
mediastinum), and (b) below the opening of azygos vein
(i.e., in the middle mediastinum).
If SVC is obstructed above the opening of azygos vein,
the venous blood from the upper half of the body is
shunted to right atrium through azygos vein. The main
collateral pathways are provided by the superior intercostal
veins. The superficial veins of chest wall do not receive
sufficient blood to cause their prominence. If at all they
become prominent, the prominence is limited up to the
costal margin only (Fig. 21.3).
If SVC is obstructed below the opening of the azygos
vein, the venous blood from the upper half of the body is
returned to the right atrium through inferior vena cava
through the collateral pathways, formed between the
tributaries of superior and inferior vena cavae (caval
caval shunt). Clinically in this condition, a subcutaneous
anastomotic channel between the superficial epigastric
vein and lateral thoracic vein (thoraco-epigastric vein) is
seen on the anterior aspect of the thoraco-abdominal wall
(Fig. 20.3).
AORTA
The aorta is the largest artery (arterial trunk) of the body
which carries the oxygenated blood from the left ventricle
and distributes it to all the parts of the body.
Parts of the Aorta (Fig. 21.4)

For the convenience of description, the aorta is divided into
the following four parts:
1. Ascending aorta.
Prominence of vein
Thoraco-epigastric
vein
Fig. 21.3 Prominence veins on the front of trunk in

obstruction of superior vena cava; A, obstruction above the
opening of azygos vein; B, obstruction below the opening
of azygos vein.
Arch of aorta (2)
Sternal
angle
T4
Ascending
aorta (1)
Descending
thoracic aorta (3)
Pericardium
Diaphragm
Abdominal aorta (4)
T12
Fig. 21.4 Parts of the thoracic aorta.
285
286
2. Arch of aorta.
4. Abdominal aorta.
N.B. The first three parts are confined to the thoracic cavity
and together form the thoracic aorta.
ASCENDING AORTA
Origin and Course
1. Ascending aorta arises from the upper end of the left
ventricle (i.e., aortic vestibule) and continues as an arch
of aorta at the sternal angle.
2. It is about 5 cm long and its diameter is about 3 cm. It is
completely enclosed in the pericardium. It begins behind
the left half of the sternum at the level of the lower
border of left 3rd costal cartilage, runs upwards, forwards
and to the right to continue as the arch of aorta at the
level of sternal angle.
Aortic Sinuses (Sinuses of the Valsalva)

The root of aorta presents three dilatations called aortic
sinuses of Valsalva (Fig. 21.5). These dilatations are just above
the cusps of the aortic valve. These positions are: anterior,
left posterior, and right posterior.
Anterior aortic sinus gives origin to the right coronary
artery, hence it is also called right coronary sinus.
Left posterior aortic sinus gives origin to the left coronary
artery, hence it is also called left coronary sinus.
Right posterior aortic sinus is termed non-coronary
sinus.
Aortic bulb (Fig. 21.5) is a bulge in the right wall of the
ascending aorta at its union with the arch of the aorta.
Relations
Anterior: From below upwards these are as follows:
1. Infundibulum of right ventricle.
2. Pulmonary trunk.
3. Pericardium.
Posterior: From before backwards and to right these are as

follows:
1. Transverse sinus of pericardium.
2. Right pulmonary artery.
3. Right principal bronchus.
(a) To the right:
(i) Right atrium.
(ii) Superior vena cava.
(b) To the left:
(i) Left atrium.
(ii) Pulmonary trunk.
Branches
1. Right coronary artery from anterior aortic sinus.
2. Left coronary artery from left posterior aortic sinus.
Development
The ascending aorta develops from the truncus arteriosus
after its partition by the spiral septum.
Aneurysm of ascending aorta: It occurs at the bulb of the
ascending aorta. The bulb of aorta is a dilatation in the right
wall of ascending aorta which is subjected to constant thrust
of the forceful blood current ejected from the left ventricle. It
may compress the right atrium, SVC or right principal
bronchus. Its rupture (a serious complication) leads to
accumulation of blood in the pericardial cavity
(hemopericardium).
ARCH OF AORTA
The arch of aorta is the continuation of ascending aorta at
the level of sternal angle and continues as descending
thoracic aorta at the level of sternal angle. Thus it (both)
begins as well as terminates at the level of sternal angle. It is
situated in the superior mediastinum. At the beginning the
arch is anteriorly located while its termination is posteriorly
located, very close to the left side of T4 vertebra. The
summit of arch reaches the level of middle of manubrium
sterni.
Arch of aorta
Course
Aortic bulb
Aortic sinuses
Fig. 21.5 Ascending aorta showing aortic sinuses (sinuses

of the Valsalva) and aortic bulb.
The arch of aorta begins at the level of the right 2nd costal
cartilage and runs upwards, backwards, and to the left, in
front of the bifurcation of the trachea. Having reached the
back of the middle of the manubrium, it turns backwards
and downwards behind the left bronchus up to the level of
lower border of T4 vertebra where it continues as the
descending thoracic aorta.
N.B.
Inferior:
The arch of aorta arches over the root of left lung.

It begins and ends at the same level, i.e., at sternal angle.
It begins anteriorly and ends posteriorly.
Relations (Figs 21.6 and 21.7)

1.
2.
3.
4.
5.
Trachea.
Esophagus.
Left recurrent laryngeal nerve.
Thoracic duct.
Vertebral column.
1.
2.
3.
4.
5.
Brachiocephalic trunk.
Left common carotid artery.
Left subclavian artery.
Left brachiocephalic vein.
Thymus.
N.B. Arch of aorta is related for 5 structures on each aspect.
Anterior and to the left:

1.
2.
3.
4.
Left lung and pleura.

Left phrenic nerve.
Left vagus nerve.
Left cardiac nerves (i.e., superior
cervical cardiac branch of left
sympathetic chain and inferior
cardiac branch of left vagus nerve).
5. Left superior intercostal vein.
Trachea (1)
Left bronchus.
Bifurcation of pulmonary trunk.
Ligamentum arteriosum.
Superficial cardiac plexus.
Superior:
Posterior and to the right:
Left recurrent
laryngeal nerve (3)
1.
2.
3.
4.
5.
Branches
1. Brachiocephalic (innominate) artery.
2. Left common carotid artery.
3. Left subclavian artery.
N.B. Occasionally a fourth branch called thyroidea ima
artery may arise from the arch of aorta.
Esophagus (2)
Left cardiac
nerves (4)
Thoracic duct (4)

Left phrenic
nerve (2)
Root of left lung
Left superior
intercostal vein (5)
Root of left lung
Left vagus nerve (3)
Left common
carotid artery (2)
Left recurrent
laryngeal nerve (4)
Superficial cardiac
plexus (5)
Brachiocephalic
trunk (1)
Left subclavian
artery (3)
Left brachiocephalic
vein (4)
Ligamentum
arteriosum (3)
Left bronchus (1)
Bifurcation of
pulmonary trunk (2)
Fig. 21.6 Relations of the arch of aorta: A, posterior and to the right (vertebral column (5) is not shown); B, anterior and to
the left (left lung and pleura (1) are not shown); C, inferior; D, superior (thymus (5) is not shown).
287
288
Sternum
Thymus
Left lung and pleura
Right lung and pleura
Left phrenic nerve

Cardiac branches of sympathetic
chain and vagus nerve
Left vagus nerve
SVC
Right phrenic nerve
ARCH
Trachea
Right vagus nerve
Left recurrent laryngeal nerve

Esophagus
Thoracic duct
Vertebra
Fig. 21.7 Cross section of superior mediastinum showing relations of arch of aorta (SVC=superior vena cava).
Development
The arch of aorta develops from the following sources:
1.
2.
3.
4.
Aortic sac.
Left horn of aortic sac.
Left fourth aortic arch artery.
Left dorsal aorta (between the attachment of the fourth
aortic arch (artery) and 7th cervical intersegmental artery.
Aortic knuckle: In X-ray chest (PA view), the shadow of
arch of aorta appears as small bulb-like projection at the
upper end of the left margin of the cardiac shadow called
aortic knuckle. The aortic knuckle may become prominent
in old age due to undue folding of the arch caused by
atherosclerosis.
Coarctation of aorta (Fig. 21.8): It is congenital narrowing
of the aorta just proximal or distal to the entrance of the
ductus arteriosus. Accordingly it is termed preductal type
and postductal type of coarctation of aorta, respectively. It
probably occurs due to hyperinvolution of the ductus
arteriosus. The ductus arteriosus is usually obliterated to
form ligamentum arteriosum in postductal type of
coarctation of aorta. The collateral circulation develops
between the branches of the subclavian arteries and
those of descending aorta.
Clinical features:
1. There is difference in the blood pressure of the
upper and lower limbs (i.e., high blood pressure in
upper limbs and low unrecordable blood pressure in the
lower limbs).
2. Notching of the lower borders of the ribs due to
dilatation of engorged posterior intercostal arteries.
3. Pulsating scapulae.
Patent ductus arteriosus (Fig. 21.9): In foetal life,

pulmonary trunk is connected to the arch of aorta (just
distal to the origin of left subclavian artery) by short
wide channel called ductus arteriosus. Normally, after
birth, it closes functionally within a week and
anatomically within 4 to 12 weeks. The obliterated
ductus arteriosus is called ligamentum arteriosum.
Non-obliterated ductus arteriosus is called patent
ductus arteriosus.
Aneurysm of the arch of aorta: It is the localized
dilatation of the arch and causes compression of
neighboring structures in the superior mediastinum
producing mediastinal syndrome. The characteristic
clinical sign in this condition is tracheal-tug which is a
feeling of tugging sensation in the suprasternal notch.
DESCENDING THORACIC AORTA

The descending thoracic aorta is the continuation of the arch
of the aorta in the posterior mediastinum.
Course
It begins on the left side of the lower border of the fourth
thoracic (T4) vertebra and descends in the posterior
mediastinum with an inclination towards the right. As a
result it terminates in front of the lower border of the body
of 12th thoracic (T12) vertebra.
At its lower end it passes through the aortic opening of
the diaphragm to continue as the abdominal aorta.
Relations
Anterior: From above downwards it is related to:
1. Left lung root.
290
3. Two left bronchial arteries (upper and lower).

4. Esophageal branches, supplying middle one-third of the
esophagus.
Dissecting aneurysm: In this condition the blood from
aortic lumen enters into its wall through a tear in the tunica
intima creating a channel of blood in the tunica media which
leads to dilatation of the aorta. Clinically, it presents as pain
in the back due to compression of intercostal nerves.
Occasionally, the aorta may rupture into the left pleural
cavity.
PULMONARY TRUNK
Origin
The pulmonary trunk is about 5 cm long and arises from the
upper part (infundibulum) of the right ventricle at the level
of the sternal end of left 3rd costal cartilage.
Course
After arising from infundibulum in the middle mediastinum,
it passes backwards and to the left and terminates below the
arch of aorta and in front of left principal bronchus by
dividing into right and left pulmonary arteries.
Relations
Anterior:
1. Sternal end of left 2nd intercostal space.
2. Left lung and pleura.
Posterior:
1. Ascending aorta.
2. Commence of left coronary artery.
3. Transverse sinus of pericardium.
To the right:
1. Ascending aorta.
2. Origin of right coronary artery.

3. Right auricle.
To the left:
1. Left coronary artery.
2. Left auricle.
Branches
Right and left pulmonary arteries.
N.B. The right pulmonary artery is larger than the left and
lies slightly at a lower level.
Pulmonary artery catheterization: Various aspects of
cardiopulmonary functions are monitored by the
cardiologists by pulmonary artery catheterization.
The catheter is passed successively as follows:
Internal jugular vein/subclavian vein Right atrium
Right ventricle Pulmonary trunk Pulmonary artery.
Sudden occlusion of pulmonary trunk by an embolus
may be a sequel to the thrombosis of deep veins of the
calf (viz. femoral vein) or large pelvic vein following
operation or immobilization in the sick-bed. When the
block is complete, death ensues rapidly.
THYMUS
The thymus is a bilobed lymphoid organ situated in the
superior mediastinum and often extends above in the root of
neck and below in the upper part of anterior mediastinum. It
is usually prominent in children and gradually increases in
size till puberty, when it weighs about 40 g. Thereafter it
atrophies and gets infiltrated by fibrous and fatty tissue. It is
related anteriorly to sternohyoid and sternothyroid muscles,
and sternum; and posteriorly to pericardium, arch of aorta
and its branches, left brachiocephalic vein and trachea. It
secretes a hormone called thymosin which plays an
important role in the development of the immunity of the
body.

" Largest artery of the body
Aorta
" Bulb of aorta
Dilatation in the right wall of ascending aorta at its

union with the arch of aorta
" Largest branch of the arch of aorta
Brachiocephalic trunk
" Commonest variation in the origin of great

arteries from the arch of aorta
Origin of left common carotid artery from the

brachiocephalic trunk
" Aortic knuckle
Projection at the upper end of the left margin of the

cardiac shadow in PA view of X-ray chest
" Part of aorta mostly affected by dissecting

aneurysm
Descending thoracic aorta
" Smallest part of the aorta
Ascending aorta
" Sinuses of Valsalva
Three dilatations in the ascending aorta above the

semilunar valves
Clinical Case Study

A mother took her 12-year-old son to the hospital and
complained that he feels weakness even after slight
exertion (reduced exercise tolerance), leg cramps on
walking and shortness of the breath. On examination,
the doctors noticed radiofemoral delay. Blood pressure
was 126/20 mmHg in upper limbs and 80/60 mmHg in
the lower limbs. The X-ray chest showed notching of
the lower borders of the ribs. Clinically he was
diagnosed as a case of coarctation of aorta, which was
confirmed later by echocardiography.
Questions
1. What is coarctation of aorta?
2. Why there is delay in radiofemoral pulse?
3. What is the cause of high blood pressure in the
upper limbs and low blood pressure in the lower
limbs?
4. Mention the reason for notching of the ribs.

Answers
1. It is congenital stenosis of the arch of aorta, usually
distal to the origin of left subclavian artery.
2. Because subclavian arteries supplying upper limbs
arise proximal to the site of stenosis, whereas
femoral arteries supplying lower limbs arise from
aorta distal to the site of obstruction.
3. Answer is same as that of question no. 2.
4. Due to dilatation and tortuosity of the posterior
intercostal arteries which erode the costal groove of
the ribs.
291
CHAPTER
22
TRACHEA
The trachea (syn. windpipe; Fig. 22.1) is a flexible
fibrocartilaginous tube forming the beginning of the lower
respiratory tract. Its lumen is kept patent by 1620 C-shaped
rings of hyaline cartilage. The gap between the posterior free
ends of C-shaped cartilages is bridged by a band of smooth
muscle (trachealis) and a fibroelastic ligament, which permit
expansion of esophagus during the passage of bolus of food.
The arrangement of cartilages and elastic tissue in the
tracheal wall prevents its kinking and obstruction during the
movements of the head and neck.
LOCATION
The trachea extends from the lower border of cricoid
cartilage (corresponding to the lower border of C6 vertebra)
in the neck to the lower border of T4 vertebra in the thorax.
Thus upper half of the trachea is located in the neck (cervical
part) and lower half in the superior mediastinum (thoracic
part).
N.B. The extent of trachea varies as follows:
C6 to T4 in cadaver placed in supine position.
C6 to T6 in living individuals in standing position.
C6 to T3 in newborn.
Thyroid
cartilage
Cricoid cartilage
C6
Trachea
1015 cm
Right principal
bronchus
T4
Left principal bronchus
Fig. 22.1 Trachea.
12 mm in adults. For this reason endotracheal tubes are

graduated in mm.
DIMENSIONS
Length: 1012 cm.
External diameter: 2 cm in males and 1.5 cm in females.
Internal diameter: 12 mm in adult, 3 mm in newborn.
Lumen of trachea:
1. The lumen of trachea is smaller in living human beings
than in the cadavers.
2. It is 3 mm at 1 year of age; during childhood it
corresponds to the age in years (i.e., 5-year-old child will
have tracheal diameter of 5 mm) with a maximum of
COURSE
The trachea is the continuation of the larynx and begins at
the lower border of the cricoid cartilage at the level of C6
vertebra, about 5 cm above the jugular notch.
It enters the thoracic inlet in the midline and passes
downwards and backwards behind the manubrium to
terminate by bifurcating into two principal bronchi, a little
to the right side at the lower border of T4 vertebra
corresponding to the sternal angle.
294
Pseudostratified ciliated
columnar epithelium
Lamina propria
Pseudostratified
ciliated columnar
epithelium
Tracheal (mixed serous

and mucous) glands
Lamina propria
Tracheal (mixed serous
and mucous) glands
Perichondrium
Perichondrium
Hyaline cartilage
(C-shaped)
L/P
Hyaline cartilage
H/P
Fig. 22.4 Microscopic structure of trachea (L/P =low power, H/P =high power). (Source: Box 16.2, Page 349, Textbook of
Histology and a Practical Guide, 2e, JP Gunasegaran. Copyright Elsevier 2010, All rights reserved.)
2. Submucosa: It consists of loose areolar tissue containing

large number of serous and mucous glands.
3. Cartilage and smooth muscle layer: It is made up of
horseshoe-shaped (C-shaped) hyaline cartilaginous
rings, which are deficient posteriorly. The posterior gap
is filled chiefly by the smooth muscle (trachealis) and
fibroelastic fibres.
4. Perichondrium: It encloses the cartilage.
5. Fibrous membrane: It is a layer of dense connective
tissue, containing neurovascular structure.
N.B. There is no clear demarcation between lamina propria
and submucosa.
VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

Blood supply to the trachea is by inferior thyroid arteries.

Venous drainage of the trachea occurs into the left
brachiocephalic (innominate) vein.
Lymphatic drainage of the trachea is into pretracheal and
paratracheal lymph nodes.
NERVE SUPPLY
Nerve supply occurs by the autonomic nerve fibres:

Parasympathetic fibres are sensory and secretomotor to

the mucous membrane, and motor to the trachealis muscle.
Sympathetic fibres are vasomotor.
Tracheal shadow in radiograph: It is seen as a vertical
translucent shadow in front of cervico-thoracic spine. The
translucency is due to the presence of air in the trachea.
Palpation of trachea: Clinically, trachea is palpated in the

suprasternal notch. Normally, it is median in position but
appreciable shift of trachea to right or left side indicates
the mediastinal shift.
Importance of carina: It is a keel-like median ridge in the
lumen at the bifurcation of trachea. The lowest tracheal ring
at the bifurcation of trachea is thick in its central part. From
the lower margin of this thick central part a keel-shaped
(hook-shaped) process projects downwards and backwards
between the right and left principal bronchi. It has both
functional and pathological importance.
Functional importance: The mucosa of trachea over the
carina is most sensitive. The cough reflex is usually
initiated here, which helps to clear the sputum.
Pathological significance: It is visible as a sharp sagittal
ridge at the tracheal bifurcation during bronchoscopy,
hence serves as a useful landmark. It is located about
25cm from the incisor teeth and 30cm from the nostrils.
If the tracheobronchial lymph nodes in the angle
between the main (principal) bronchi are enlarged due
to spread of bronchiogenic carcinoma, the carina
becomes distorted and flattened.
Importance of mucous secretion in tracheal lumen: It
helps to trap the inhaled foreign particles and solid
mucous is then expelled during coughing. The cilia of
lining epithelium of mucous membrane also beat upwards
pushing the mucous upwards. The fibroelastic ligament
prevents overdistension of tracheal lumen while trachealis
muscle reduces the diameter on contraction during
coughing which involves increased velocity of expired air
required for cleaning the air passages.
ESOPHAGUS
The esophagus (Fig. 22.5) is a narrow muscular tube
extending from pharynx to the stomach. It is about 25 cm
long and provides passage for chewed food (bolus) and
liquids during the third stage of deglutition. The anatomy of

esophagus is clinically important because of its involvement
in various diseases such as esophagitis, esophageal varices
and cancer. It begins with lower part of the neck and
terminates in the upper part of the abdomen by joining the
upper end of the stomach.
DIMENSIONS AND LUMEN

Length: 25 cm (10 inches).
Width: 2 cm.
Lumen: It is flattened anteroposteriorly. Normally it is kept
closed (collapsed) and opens (dilates) only during the
passage of the food.
COURSE
The esophagus begins in the neck at the lower border of the
cricoid cartilage (at the lower border of C6 vertebra),
descends in front of the vertebral column passes through
superior and posterior mediastina, pierces diaphragm at the
level of T10 vertebra and ends in the abdomen at the cardiac
orifice of the stomach at the level of T11 vertebra (Fig. 22.5).
CURVATURES
The cervical portion of esophagus commences in the
midline, then inclines slightly to the left of the midline at the
root of neck, enters the thoracic inlet, passes through
superior mediastinum. At the level of T5 vertebra, it returns

to the midline, but at T7 it again deviates to the left and
inclines forwards to pass in front of the descending thoracic
aorta and pierces diaphragm 2.5 cm to the left of the midline
(a thumbs breadth from the side of sternum), at the level of
7th left costal cartilage. Here fibres of the right crus of
diaphragm sweep around the esophageal opening forming a
sling around the esophagus. It enters the abdomen to join
the stomach at the level of T11 vertebra. Thus esophagus
presents the following curvatures:
1. Two side-to-side curvatures, both towards the left.
(a) First at the root of the neck, before entering the
thoracic inlet.
(b) Second at the level of T7 vertebra, before passing in
front of the descending thoracic aorta.
2. Two anteroposterior curvatures.
(a) First corresponding to the curvature of cervical
spine.
(b) Second corresponding to the curvature of thoracic
spine.
CONSTRICTIONS
Normally, there are four sites of anatomical constrictions/
narrowings in the esophagus. The distance of each
Upper incisor teeth
Pharynx
Cricopharyngeus
Cervical part
(4 cm)
C6
1. Cricopharyngeus
Pharyngo-esophageal
junction
Thoracic part (20 cm)
3. Left bronchus
Muscular sling formed by
right crus of diaphragm
Abd. part
(12 cm)
25 cm
2. Arch of aorta
T11
6 in
(15 cm)
Fig. 22.5 Esophagus (Abd.=abdominal).
Cardiac orifice
4. Esophageal
hiatus in
diaphragm
9 in
(22 cm)
11 in
(27 cm)
15 in
(40 cm)
Fig. 22.6 Anatomical sites of constrictions in esophagus.

On the right side distances of these sites from the upper
incisor teeth are given.
295
296
constriction is measured from the upper incisor teeth. The

constrictions are as follows (Fig. 22.6):
1. First constriction, at the pharyngo-esophageal junction,
9 cm (6 inches) from the incisor teeth.
2. Second constriction, where it is crossed by the arch of
aorta, 22.5 cm (9 inches) from the incisor teeth.
3. Third constriction, where it is crossed by the left
principal bronchus, 27.5 cm (11 inches) from the incisor
teeth.
4. Fourth constriction, where it pierces the diaphragm,
40 cm (15 inches) from the incisor teeth.
The sites of constriction, their respective distances from
the upper incisor teeth and their vertebral level are given in
Table 22.1.
PARTS OF THE ESOPHAGUS

The esophagus is divided into the following three parts:
1. Cervical part (4 cm in length).
2. Thoracic part (20 cm in length).
3. Abdominal part (12 cm in length).
The cervical part extends from the lower border of cricoid
cartilage to the superior border of manubrium sterni
(described in detail in the Textbook of Anatomy: Head, Neck
and Brain, Vol. III by Vishram Singh.
The thoracic part extends from superior border of
manubrium sterni to the esophageal opening in the
diaphragm.
N.B. The narrowest part of esophagus is its commencement

at the cricopharyngeal sphincter.
Clinical significance of esophageal constrictions: The
anatomical constrictions of esophagus are of considerable
clinical importance due to the following reasons:
1. These are the sites where swallowed foreign bodies may
stuck in the esophagus.
2. These are the sites where strictures develop after
ingestion of caustic substances.
3. These sites have predilection for the carcinoma of the
esophagus.
4. These are sites through which it may be difficult to pass
esophagoscope/gastric tube (Fig. 22.7).
Table 22.1 Sites of constriction in the esophagus

Site of constriction
Vertebral level Distance from upper

incisor teeth
At the pharyngoesophageal junction

(cervical
constriction)
C6
At crossing of arch
of aorta (aortic
constriction)
T4
9 inches (22 cm)
At crossing of left
principal bronchus
(bronchial
constriction)
T6
11 inches (27 cm)
At the opening in the

diaphragm
(diaphragmatic
constriction)
T10
15 inches (40 cm)
Gastric tube
Cervical constriction
(6"/15 cm)
Aortic constriction
(9"/22 cm)
Bronchial constriction
(11"/27 cm)
6 inches (15 cm)

Diaphragmatic
constriction
(15"/40 cm)
Fig. 22.7 Anatomical sites of the esophageal constrictions

and passage of the gastric tube.
RELATIONS OF THORACIC PART OF THE ESOPHAGUS
The abdominal part extends form esophageal opening in

the diaphragm to the cardiac end of the stomach.
Anterior: From above downwards these are as follows:

1. Trachea.
2. Arch of aorta.
3. Right pulmonary artery.
4. Left principal bronchus.
5. Left atrium enclosed in the pericardium.
6. Diaphragm.
RELATIONS (Figs 22.8 and 22.9)

RELATION OF CERVICAL PART OF THE ESOPHAGUS
For description refer to the Textbook of Anatomy: Head,
Neck and Brain, Vol III by Vishram Singh, page 181.
Esophagus
Right recurrent
laryngeal nerve
Left recurrent
laryngeal nerve
Thoracic duct
Right vagus
nerve

Left vagus nerve
Right pulmonary
artery
Arch of aorta
Azygos vein
Left pulmonary
artery
Thoracic aorta
Outline of
pericardium
Muscular sling
formed by right
crus of diaphragm
Stomach
Fig. 22.8 Anterior and lateral relations of esophagus.
Left vagus nerve
Esophagus
Right vagus nerve
Thoracic duct
Descending
thoracic aorta
Azygos vein
Hemiazygos
vein
Right lung and pleura

T8
Right posterior
intercostal artery
Fig. 22.9 Cross section of posterior mediastinum at the level of T8 vertebra showing posterior relations of the esophagus.
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298
Posterior:
1.
2.
3.
4.
5.
6.
Vertebral column.
Right posterior intercostal arteries.
Thoracic duct.
Azygos vein.
Hemiazygos veins (terminal parts).
Descending thoracic aorta.
To the right:
2. Azygos vein.
3. Right vagus nerve.
To the left:
1.
2.
3.
4.
5.
6.
Arch of aorta.
Left subclavian artery.
Thoracic duct.
Left lung and pleura.
Descending thoracic aorta.
N.B. In the esophageal aperture of the diaphragm, the left

vagus nerve (now called anterior gastric nerve) is related
anteriorly and right vagus nerve (now called posterior
gastric nerve) is related posteriorly.
RELATIONS OF ABDOMINAL PART OF THE ESOPHAGUS

Anterior:
1. Posterior surface of the left lobe of the liver.
2. Left gastric nerve.
1. Left crus of diaphragm.
2. Right gastric nerve.
N.B. The abdominal part of esophagus is shortest (1 to
2 cm long) and is the only part covered with serous
membranethe peritoneum.
ARTERIAL SUPPLY
Cervical part is drained by inferior thyroid veins.

Thoracic part is drained by azygos and hemiazygos veins.
Abdominal part is drained by two venous channels, viz.
(a) hemiazygos vein, a tributary of inferior vena cava, and
(b) left gastric vein, a tributary of portal vein.
Thus abdominal part of esophagus is the site of portocaval
anastomosis.

Esophageal varices: The lower end of esophagus is one of
the important sites of portocaval anastomosis. In portal
hypertension, e.g., due to the cirrhosis of liver there is back
pressure in portal circulation. As a result, collateral channels
of portocaval anastomosis not only open up but become
dilated and tortuous to form esophageal varices. The
ruptured esophageal varices cause hematemesis (vomiting
of blood).
LYMPHATIC DRAINAGE
From cervical part, the lymph is drained into deep cervical
lymph nodes.
From thoracic part, the lymph is drained into posterior
mediastinal lymph nodes.
From abdominal part, the lymph is drained into left
gastric lymph nodes.
NERVE SUPPLY
Posterior:
VENOUS DRAINAGE
Blood supply to the cervical part is by inferior thyroid

arteries.
Blood supply to the thoracic part is by esophageal
branches of
(a) descending thoracic aorta, and
(b) bronchial arteries.
Blood supply to the abdominal part is by esophageal
branches of
(a) left gastric artery, and
(b) left inferior phrenic artery.
The esophagus is supplied by both parasympathetic and

sympathetic fibres.
The parasympathetic fibres are derived from recurrent
laryngeal nerves and esophageal plexuses formed by vagus
nerves. They provide sensory, motor, and secretomotor
supply to the esophagus.
The sympathetic fibres are derived from T5T9 spinal
segments are sensory and vasomotor.
Referred pain of esophagus: The pain sensations mostly
arises from the lower part of the esophagus as it is
vulnerable to acid-peptic esophagitis. Pain sensations are
carried by sympathetic fibre to the T4 and T5 spinal
segments.
Therefore, esophageal pain is referred to the lower
thoracic region and epigastric region of the abdomen, and
at times it becomes difficult to differentiate esophageal pain
from the anginal pain.
MICROSCOPIC STRUCTURE
Histologically, esophageal tube from within outwards is
made up of the following four basic layers (Fig. 22.10):
1. Mucosa: It is composed of the following components:
(a) Epitheliumhighly stratified squamous and nonkeratinized.
(b) Lamina propriacontains cardiac esophageal
glands in the lower part only.
(c) Muscularis mucosavery-very thick and made up
of only longitudinal layer of smooth muscle fibres.
2. Submucosa: It contains mucous esophageal glands.
3. Muscular layer:
(a) In upper one-third, it is made up of skeletal muscle.
(b) In middle one-third, it is made up of both skeletal
and smooth muscles.
(c) In lower one-third, it is made up of smooth muscle.
4. Fibrous membrane (adventitia). It consists of dense
connective tissue with many elastic fibres.
N.B. A clinical condition in which the stratified squamous
epithelium of esophagus is replaced by the gastric
epithelium is called Barrett esophagus. It may lead to
esophageal carcinoma.
DEVELOPMENT OF THE ESOPHAGUS AND TRACHEA

The esophagus develops from foregut. The respiratory tract
develops from foregut diverticulum called laryngotracheal
diverticulum/tube. The following two important events
occur in the development of esophagus:
(a) Separation of laryngotracheal tube by the formation of
laryngotracheal septum.
(b) Recanalization of obliterated lumen.
N.B. The failure of canalization of the esophagus leads to

esophageal atresia and maldevelopment of laryngotracheal
septum between the esophagus and trachea leads to
tracheoesophageal fistula.
Radiological examination of the esophagus by barium
swallow: It is performed to detect (a) enlargement of the
left atrium due to mitral stenosis, (b) esophageal strictures,
and (c) carcinoma and achalasia cardia.
N.B. In normal case, the barium swallow examination

presents 3 indentations in its outline caused by the
aortic arch, left principal bronchus, and left atrium.
Esophagoscopy: It is performed to visualize the interior
of the esophagus; while passing esophagoscope, the
sites of normal constrictions should be kept in mind.
Achalasia cardia: It is a clinical condition in which
sphincter at the lower end of esophagus fails to relax
when the food is swallowed. As a result food accumulates
in the esophagus and its regurgitation occurs. This
condition occurs due to neuromuscular incoordination,
probably due to congenital absence of ganglion cells in
the myenteric plexus of nerves in the esophageal wall. A
radiographic barium swallow examination of the
esophagus reveals a characteristic birds beak/rat tail
appearance.
Dysphagia (difficulty in swallowing): It occurs due to:
(a) compression of esophagus from outside by aortic
arch aneurysm, enlargement of lymph nodes,
abnormal right subclavian artery (passing posterior
to esophagus), etc. and
(b) narrowing of lumen due to stricture or carcinoma.
Tracheoesophageal fistula (Fig. 22.11): It is a commonest
congenital anomaly of esophagus which occurs due to
failure of separation of the lumen of tracheal tube from
Glandular duct
Esophageal (mucous) glands
Lamina propria
Muscularis mucosa
Stratified squamous
epithelium
Tracheoesophageal
fistula
Trachea
Upper esophagus
Lower esophagus
Stomach
Fig. 22.10 Microscopic structure of esophagus. (Source:

Box 12.6, Page 223, Textboook of Histology and a Practical
Guide, JP Gunasegaran. Copyright Elsevier 2010, All rights
reserved.)
Fig. 22.11 Tracheoesophageal fistula.
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300
that of esophagus by a laryngotracheal septum. In the

most commonest type of tracheoesophageal fistula, the
upper esophagus ends blindly and lower esophagus
communicates with trachea at the level of T4 vertebra.
Clinically it presents as: (a) hydramnios because fetus is
unable to swallow amniotic fluid, (b) stomach is distended
with air, and (c) infant vomit every feed given or may cough
up bile. The fistula must be closed surgically to avoid
passage of swallowed liquids into the lungs.
Malignant tumors of esophagus: They most commonly
occur in its lower one-third.
The lymph vessels from lower one-third of the esophagus

descend through the esophageal opening of the diaphragm
and drain into the celiac lymph nodes around the celiac
trunk. A malignant tumor from lower one-third of esophagus,
therefore, spreads below the diaphragm into these lymph
nodes. Consequently, surgical resection of the lesion
includes not only the primary site (i.e., esophagus) but also
celiac lymph nodes and all the regions that drain into these
lymph nodes such as stomach, upper half of the duodenum,
spleen, and omenta. The continuity of gut is restored by
performing an esophagojejunostomy.
CHAPTER
23
Thoracic Duct, Azygos

and Hemiazygos
Veins, and Thoracic
Sympathetic Trunks
THORACIC DUCT
The thoracic duct is the largest lymphatic vessel (trunk or
great lymph channel) which drains lymph from most of the
body into the bloodstream. The lymph in the thoracic duct is
milky-white in appearance because it contains a product of
fat digestion (chyle) from the intestine. The duct appears
beaded due to the presence of numerous valves in its lumen.
Area of drainage: The thoracic duct drains the lymph
from all the parts of the body except the (a) right side of the
head and neck, (b) right side of the chest wall, (c) right lung,
(d) right side of the heart, and (e) right surface of the liver.
Right upper quadrant

of the body
(drained by right
lymphatic duct)
Whole of body except

right upper quadrant
(drained by
thoracic duct)
N.B. Thoracic duct drains lymph from whole of the body

except the right upper quadrant of the body which is
drained by the right lymphatic duct (Fig. 23.1).
Extent: The thoracic duct extends to the upper end of

cisterna chyli on the posterior abdominal wall at the lower
border of T12 vertebra to the junction of left internal jugular
and left subclavian veins at the root of the neck.
Measurements: The measurements of the thoracic duct are as
follows:
Length: 45 cm (18 inches).
Width of lumen: 5 mm (at the ends but narrow in the middle).
FORMATION, COURSE, AND

TERMINATION (Fig. 23.2)
The duct begins in the abdomen at the lower border of T12
vertebra, as a continuation of cisterna chyli (lying in front of
the bodies of L1 and L2 vertebrae) and enters the thorax
through the aortic opening of the diaphragm. It then ascends
in the posterior mediastinum to the right of midline on the
front of vertebral bodies. On reaching the T5 vertebra, it
crosses the midline from right to left side and enters the
superior mediastinum to run along the left border of the
esophagus and reaches the root of the neck.
Fig. 23.1 Lymphatic drainage of the body. Note that the

lymph from right upper quadrant of the body is drained by
the right lymphatic duct. The lymph from remaining area of
the body is drained by the thoracic duct.
At the root of neck it arches laterally at the level of C7

vertebrain front of vertebral system (e.g., vertebral artery
and vertebral vein) and left cervical sympathetic trunk and
behind the carotid system (e.g., left common carotid artery,
left internal jugular vein, and left vagus nerve). The summit
of arch lies 34 cm above the clavicle. Finally, the duct
304
D. In the root of the neck (Fig. 23.3)

Anterior: Carotid sheath containing left common carotid
artery, left internal jugular vein, and left vagus nerve.
Posterior:
1. Vertebral artery and vein.
2. Scalenus anterior muscle (medial border).
3. Phrenic nerve.
4. Thyrocervical trunk and its branches (e.g.,
suprascapular, transverse cervical, and
inferior thyroid arteries).
TRIBUTARIES
The tributaries of the thoracic duct are as follows (Fig. 23.4):
A. In the abdomen
Efferent from lower six intercostal lymph nodes of both
sides.
B. In the thorax
1. A pair of the ascending lymph trunks which drains
lymph from the upper lumbar lymph nodes (para-aortic
lymph nodes).
2. A pair of the descending lymph trunks which drain
lymph from the posterior intercostal lymph nodes of
upper six spaces.
3. Lymph vessels from the posterior mediastinal lymph
nodes.
C. In the neck
1. Left jugular lymph trunk, draining lymph from the
neck.
2. Left subclavian lymph trunk, draining lymph from the
left upper limb.
3. Left bronchomediastinal trunk.
Injury of thoracic duct: The thoracic duct is thin walled
and may be colorless, therefore, it is sometimes injured
inadvertently during surgical procedures in the posterior
mediastinum. Laceration of the thoracic duct during lung
surgery results in chyle entering into the pleural cavity
producing a clinical condition called chylothorax.
The cervical part of thoracic duct may be damaged
during block dissection of the neck. It should be ligated
immediately. If ligated, the lymph returns by anastomotic
channels. But if the injury is not detected at the time of
operation, and hence not ligated, it may cause an
unpleasant chylus fistula and leakage of lymph. Immediate
ligation of duct is required to stop the leakage.
Obstruction of thoracic duct: Sometimes in filarial
infection, the thoracic duct is obstructed by microfilarial
parasites (Wuchereria bancrofti) leading to widespread
effects, such as chylothorax, chyloperitoneum, chyluria,
and even the accumulation of chyle in the tunica vaginalis
(chylocele).
Right lymphatic duct

Left jugular lymph trunk
Right jugular trunk
Right subclavian trunk
Right
bronchomediastinal
trunk
Left subclavian lymph trunk
Left bronchomediastinal
lymph trunk
Thoracic duct
Descending thoracic
lymph trunk
Cisterna chyli
Intestinal lymph trunks
Lumbar lymph trunks
Fig. 23.4 Tributaries of the thoracic duct.
Network of
lymph channels
Two longitudinal
lymph channels
Thoracic duct
The functions of azygos vein are as follows:

1. It drains venous blood from the thoracic wall and upper
lumbar region.
2. It forms an important collateral channel connecting the
superior vena cava and inferior vena cava.
FORMATION
The formation of azygos vein is variable. It is formed in one
of the following ways:
Stage I
Stage II
Stage III
Fig. 23.5 Development of the thoracic duct.
Development
There are three stages in the development of the thoracic
duct (Fig. 23.5).
Stage I: In this stage, network of lymph channels is seen in
front of the thoracic part of the vertebral column.
Stage II: In this stage, two longitudinal lymph channels
appear, in the network of lymph channels, one on the left
and another on the right with a number of cross
communications.
Stage III: In this stage, the cross communication appears
opposite the T5 vertebra, right longitudinal channel below
this cross communication and left longitudinal channel
above this cross communication persists and form the
thoracic duct. All the other parts disappear.
1. Formed by the union of right subcostal and right

ascending lumbar vein at the level of T12 vertebra
(common).
2. Arises from the posterior aspect of the inferior vena cava
(IVC) near the renal veins.
3. As a continuation of right subcostal vein.
4. Occasionally, it may arise from right renal or right first
lumbar vein.
COURSE AND TERMINATION

The azygos vein after formation ascends up and leaves the
abdomen by passing through the aortic opening of the
diaphragm and enters the posterior mediastinum. There it
ascends vertically lying in front of vertebral column up to the
level of T4 vertebra, where it arches forwards above the
hilum of the right lung to terminate in the superior vena
cava at the level of the 2nd costal cartilage.
Arch of
azygos vein
3
AZYGOS VEIN (Fig. 23.6)

The azygos vein is present only on the right side in the upper
part of the posterior abdominal wall and the posterior
mediastinum. It connects the inferior vena cava with the
superior vena cava. It is provided with valves and may appear
tortuous.
Azygos vein
Accessory
6 hemiazygos vein
AZYGOS AND HEMIAZYGOS VEINS

The term azygos means single i.e. without a companion.
Azygos system of veins consists of azygos, hemiazygos, and
accessory hemiazygos veins. These veins lie in front of
thoracic part of vertebral column and play an important role
in the venous drainage of the thorax.
Superior
vena cava
7
8
T8
8
9
10
10
11
11
Right subcostal
vein
Hemiazygos vein
Left subcostal
vein
Left ascending
lumbar vein
Right ascending
lumbar vein
Left renal vein
Right renal vein

Inferior vena cava
Fig. 23.6 Azygos, hemiazygos, and accessory hemiazygos

veins.
305
306
RELATIONS
Anterior: Esophagus (right edge).

Posterior:
1. Lower 8th thoracic vertebrae.
2. Right posterior intercostal arteries.
To the right:
2. Greater splanchnic nerves.
To the left:
1. Thoracic duct.
3. Esophagus (right border).
It pierces the left crus of the diaphragm and ascends

vertically in front of the left side of the vertebral column up
to the level of T8 vertebra. At T8 vertebra it turns to the
right and crosses in front of the vertebral column posterior
to the aorta, esophagus and thoracic duct to terminate in
the azygos vein.
The arch of azygos vein is related below to the root of right

lung, on right side to the right lung and pleura, and left side
to the right border of esophagus, trachea, and right vagus
nerve.
TRIBUTARIES
The tributaries of the hemiazygos veins are as follows:
1.
2.
3.
4.
Lower three (9th11th) left posterior intercostal veins.

Left subcostal vein.
Left ascending lumbar vein.
Small esophageal and mediastinal veins.
ACCESSORY HEMIAZYGOS VEIN

TRIBUTARIES
The tributaries of the azygos vein are as follows:
1. Lower 7th right posterior intercostal veins except first.
2. Right superior intercostal vein (formed by union of 2nd,
3rd, and 4th right posterior intercostal veins).
3. Hemiazygos vein (at the level of T7 or T8 vertebra).
4. Accessory hemiazygos vein (at the level of T8 or T9
vertebra).
5. Right subcostal vein.
6. Right bronchial vein.
7. Right ascending lumbar vein.
8. Esophageal veins with the exception of those at its lower
end.
9. Mediastinal veins.
10. Pericardial veins.
In case of obstruction of SVC, it serves as the main collateral
channel to shunt the blood from the upper half of the body to
IVC (for details see Clinical correlation on p. 285.
The accessory hemiazygos vein (syn. superior hemiazygos

vein; Fig. 23.6) lies on the left side only and corresponds to
the upper part of the azygos vein (i.e., mirror image of the
upper part of the azygos vein).

The accessory hemiazygos vein begins at the medial end of
left 4th or 5th intercostal space and descends to the left side
of the vertebral column. At the level of T8 vertebra, it turns
to the right passes in front of the vertebral column posterior
to the aorta, esophagus and thoracic duct to terminate in the
azygos vein.
N.B. Sometimes the terminal parts of hemiazygos and
accessory hemiazygos veins join together to form a common
trunk which crosses across the vertebral column to open into
the azygos vein.
TRIBUTARIES
The following are the tributaries of accessory hemiazygos
vein:
HEMIAZYGOS VEIN (Fig. 23.6)

The hemiazygos vein (syn. inferior hemiazygos vein) lies on
the left side only and corresponds to the lower part of the
azygos vein (i.e., mirror image of the lower part of the azygos
vein).
FORMATION
The hemiazygos vein formed on the left, similar to the azygos
vein, by the union of left ascending lumbar vein and left
subcostal vein. It may arise from the posterior surface of the
left renal vein.
1. Fifth to eighth (5th8th) left posterior intercostal veins.

2. Left bronchial veins (sometimes).
THORACIC SYMPATHETIC TRUNKS (Fig. 23.7)

The thoracic sympathetic trunk is a ganglionated chain
situated on either side of the vertebral column. Superiorly it
is continuous with the cervical sympathetic chain at the
thoracic inlet and inferiorly with the lumbar sympathetic
chain after passing behind the medial arcuate ligament of the
diaphragm.
only 10 ganglia (vide supra). Each ganglion lies at the level of

the corresponding intervertebral disc and is connected to the
corresponding spinal nerve by white and grey ramus
communicans.
2
BRANCHES
4
Greater splanchnic
nerves
10
10
11
11
12
12
Least splanchnic
nerve
Least splanchnic
nerve
Lesser splanchnic
nerves
Fig. 23.7 Thoracic sympathetic trunks and splanchnic

nerves.
COURSE AND RELATIONS

The sympathetic chain descends in front of the neck of the
1st rib, head of 2nd10th ribs and along the bodies of T11
and T12 vertebrae, in front of posterior intercostal nerve and
vessels, passes behind the medial arcuate ligament to become
continuous with the lumbar sympathetic trunk.
GANGLIA
Initially, each thoracic sympathetic trunk has 12 ganglia
corresponding to the 12 thoracic spinal nerves. The first
ganglion commonly fuses with the inferior cervical
sympathetic ganglia to form the cervico-thoracic/stellate
ganglion. The second ganglion also may occasionally fuse
with the first ganglion. Thus there are usually 11 ganglia in
the thoracic sympathetic trunk; sometimes there may be
The branches of thoracic sympathetic trunks are divided

into two groups: medial and lateral.
A. Medial branches
The medial branches supply the viscera. They are as follows:
1. The medial branches from 1st to 5th ganglia consist of
postganglionic fibres and are distributed to the heart,
great vessels, lungs, and esophagus through the following
plexuses:
(a) Pulmonary plexus.
(b) Cardiac plexus.
(c) Aortic plexus.
(d) Esophageal plexus.
2. Medial branches from 5th to 12th thoracic ganglia
consist of preganglionic fibres and from three splanchnic
nerves as follows:
(a) Greater splanchnic nerve: It is formed by the
preganglionic fibres arising from 5th to 9th ganglia.
It descends obliquely on the vertebral bodies, pierces
the corresponding crus of diaphragm and terminates
mainly in the celiac ganglion. Partly it also
terminates in the aorticorenal ganglion and the
suprarenal gland.
(b) Lesser splanchnic nerve: It is formed by the
preganglionic fibres from 10th and 11th ganglia. It
course is obliquely similar to the greater splanchnic
nerve, pierces the corresponding crus of diaphragm
and terminates in the celiac ganglion.
(c) Least (lowest) splanchnic nerve: It is also called renal
nerve. This tiny nerve arises from the 12th thoracic
ganglion and may even be absent. It descends
obliquely as greater and lesser splanchnic nerves,
pierces either the crus or passes behind the medial
arcuate ligament of diaphragm and terminates in
the renal plexus.
B. Lateral branches
The lateral branches supply limbs and body wall. Their
supply is pilomotor, sudomotor, and vasomotor to the skin
of these regions.
The preganglionic fibres arise from the lateral horns of
spinal segments and enter the sympathetic ganglion via white
rami communicantes of the spinal nerve. The preganglionic
fibres from the ganglion re-enter the spinal nerve via grey
rami communicantes and supply the corresponding
dermatome of the upper limb and the body wall.
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308
Thoraco-abdominal sympathectomy: The bilateral
thoraco-abdominal sympathectomy is done to relieve
severe hypertension. The surgical procedure involves
removal of sympathetic trunk from T5 to L2 ganglia and
excision of the splanchnic nerves. As a result, there occurs
splanchnic vasodilatation and consequent fall in the blood
pressure.
The upper limb sympathectomy is used to treat the
Raynaud's disease. In this, part of thoracic sympathetic
chain is excised below the level of stellate ganglion.
N.B. Injury to stellate ganglion may cause ipsilateral

Horner's syndrome.
Hypotension during spinal anesthesia: Sometimes
hypotension occurs during high spinal anesthesia due to
paralysis of sympathetic outflow to the splanchnic nerves.
Referred pain of diaphragm: The irritation of diaphragm
secondary to peritonitis causes pain due to stimulation of
the phrenic nerve (root value C3, C4, and C5). The pain is
referred to the corresponding tip of shoulder, being
supplied by the supraclavicular nerve (root value C3, C4,
and C5).
CHAPTER 1
1. The most important function of the hand in humans is:
(a)
(b)
(c)
(d)
Power grip
Hook grip
Precision grip
None of the above
2. Evolutionary changes occurred in human upper limb

include all except:
(a) Appearance
of joints permitting rotatory

movements of the forearm
(b) Addition of clavicle to act as a strut
(c) Rotation of thumb to 180 for opposition
(d) Rotation of thumb to 90 for opposition
3. Shoulder region includes all of the following regions
except:
(a)
(b)
(c)
(d)
Pectoral region
Axilla
Arm
Scapular region
Answers
1. c, 2. c, 3. c
CHAPTER 2
1. Select the incorrect statement about the clavicle:
(a)
(b)
(c)
(d)
It is only long bone which lies horizontally

It has no medullary cavity
It ossifies mainly in cartilage
It ossifies by two primary centers
2. All the statements about clavicle are correct except:

(a) It is first bone to start ossifying
(b) It acts like a strut to keep upper limb away from the
trunk
(c) It commonly fractures at the junction of its lateral
two-third and medial one-third

(d) It can be palpated throughout its extent
3. All the statements about scapula are correct except:

(a)
(b)
(c)
(d)
It has three processes

It has head and neck
It extends vertically from 1st to 8th rib
Its lateral border is thickest
4. All the structures are attached to coracoid process

except:
(a)
(b)
(c)
(d)
Coracohumeral ligament
Coracoacromial ligament
Rhomboid ligament
Long head of biceps brachii
5. Select the incorrect statement about the surgical neck

of humerus:
(a) It is commonest site of fracture of humerus
(b) It is related to axillary nerve
(c) It is a short constriction at the upper end of the
shaft below the greater and lesser tubercles

(d) It is related to posterior and anterior circumflex
humeral arteries
6. Select the incorrect statement about the lower end of
radius:
(a) It is the widest part of the bone
(b) Its posterior surface presents Listerss tubercle
(c) Groove lateral to Listers tubercle lodges the tendon
of extensor pollicis longus

(d) Its medial surface presents the ulnar notch
7. All of the following statements about ulna are correct

except:
(a) It stabilizes the forearm during supination and
pronation
(b) Its head is directed upwards
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(c) Its posterior border provides attachment to three
muscles by a common aponeurosis

(d) Its upper end presents two notches
8. Select the incorrect statement about carpal bones:
(a) Scaphoid is the most commonly fractured carpal
bone
(b) Capitate is largest carpal bone
(c) Pisiform is the first bone to ossify
(d) Lunate is most commonly dislocated carpal bone
9. All are the peculiar features of first metacarpal bone

except:
(a)
(b)
(c)
(d)
Its dorsal surface faces laterally

Its base possesses saddle-shaped articular surface
Its head is related to two sesamoid bones
Its epiphysis is at its distal end
10. Select the incorrect statement about the phalanges:

(a)
(b)
(c)
(d)
They are 14 in number

They are short long bones
All the digits have three phalanges
Heads of proximal and middle phalanges are pulleyshaped
Answers
1. c, 2. c, 3. c, 4. d, 5. a, 6. c, 7. b, 8. c, 9. d, 10. c
CHAPTER 3
1. Muscles of pectoral region include all except:
(a)
(b)
(c)
(d)
Pectoralis major
Serratus anterior
Pectoralis minor
Subclavius
2. Select the incorrect statement about the pectoralis major

muscle:
(a) It arises from lateral half of the anterior surface of
the clavicle
4. Regarding clavipectoral fascia, all of the following

statements are correct except:
(a) It lies deep to sternocostal head of the pectoralis
major
(b) It encloses subclavius and pectoralis minor muscles
(c) Vertically it extends from clavicle and axillary fascia
(d) Its thick upper part is called costoclavicular ligament
5. Clavipectoral fascia is pierced by all of the following
structures except:
(a)
(b)
(c)
(d)
Cephalic vein
Thoraco-acromial artery
Medial pectoral nerve
Lymph vessels from the breast
6. All of the following statements regarding breast are

correct except:
(a)
(b)
(c)
(d)
It lies in the superficial fascia of the pectoral region

It is a modified sebaceous gland
Vertically, it extends from 2nd to 6th rib
Horizontally, it extends from sternum to midaxillary
line
7. The deep aspect of breast is related to all of the following

muscles except:
(a)
(b)
(c)
(d)
Pectoralis major
Pectoralis minor
Serratus anterior
Aponeurosis of external oblique muscle of abdomen
8. Regarding breast cancer, which of following statements is

incorrect:
(a)
(b)
(c)
(d)
It mostly occurs in its superolateral quadrant

It is immobile and fixed
It produces retraction of nipple
Its spread to vertebral column occurs through
lymphatics
Answers
1. b, 2. a, 3. b, 4. a, 5. c, 6. b, 7. b, 8. d
(b) It is supplied by all the five spinal segments of the
brachial plexus
(c) Its clavicular head flexes the arm
(d) Its sternocostal head adducts and medially rotates
the arm
3. Select the incorrect statement about the serratus anterior
muscle:
(a) It arises by 8 digitations from upper eight ribs
(b) It is inserted into the costal surface of scapula along
its lateral border

(c) Its supplied by long thoracic nerve
(d) It is the chief protractor of the scapula
CHAPTER 4
1. The axillary sheath is derived from:
(a)
(b)
(c)
(d)
Investing layer of deep cervical fascia

Pretracheal fascia
Prevertebral fascia
Deep fascia of the axilla
2. The apex of axilla is bounded by all of the following

structures except:
(a) Clavicle
(b) Upper border of scapula
(c) Neck of humerus

(d) Outer border of the 1st rib
3. Which of the following structures is not a content of the

axilla?
(a)
(b)
(c)
(d)
Axillary vessels
Roots of brachial plexus
Axillary tail of the mammary gland
Intercostobrachial nerve
4. Select the incorrect statement about the axillary artery:

(a) It extends from outer border of 1st rib to the lower
border of teres major muscle

(b) It is divided into three parts of the pectoralis minor
muscle
(c) It usually gives rise to five branches
(d) It is the key structure of the axilla
5. Select the incorrect statement about the axillary vein:

(a)
(b)
(c)
(d)
It is continuation of subclavian vein

It lies medial to the axillary artery
It lies outside the axillary sheath
It receives venae comitantes of the brachial artery
6. Select the incorrect statement about the Erbs point:

(a) It is the point on the upper trunk of brachial plexus
where six nerves meet

(b) Traction injury of Erbs point involves C5 and C6
fibres
(c) Suprascapular and nerve to subclavius arise at this
point
(d) Dorsal scapular and long thoracic nerves arise at this
point
7. Which of the following parts of the brachial plexus is
involved in Klumpkes paralysis?
(a)
(b)
(c)
(d)
Upper trunk
Middle trunk
Lower trunk
None of the above
8. Klumpkes paralysis presents all of the following clinical

features except:
(a) Claw hand
(b) Sensory loss along the medial border of forearm and
hand
(c) Horners syndrome
(d) Wrist drop
Answers
1. c, 2. c, 3. b, 4. c, 5. a, 6. d, 7. c, 8. d
CHAPTER 5
1. Which of the following two muscles contract together
while climbing a tree?
(a)
(b)
(c)
(d)
Latissimus dorsi and trapezius

Teres major and minor
Teres major and pectoralis major
Latissimus dorsi and pectoralis major
2. All of the following muscles are supplied by dorsal

scapular nerve except:
(a)
(b)
(c)
(d)
Supraspinatus
Rhomboideus minor
Rhomboideus major
Levator scapulae
3. All of the following structures form the boundary of

triangle of auscultation except:
(a)
(b)
(c)
(d)
Trapezius
Rhomboideus major
Latissimus dorsi
Medial border of the scapulae
4. All of the following arteries take part in the formation

of anastomosis around scapula except:
(a)
(b)
(c)
(d)
Deep branch of the transverse cervical artery

Suprascapular artery
Lateral thoracic artery
5. Select the incorrect statement about the deltoid muscle:

(a)
(b)
(c)
(d)
It is shaped like an inverted Greek letter delta ()

It is supplied by axillary nerve
It abducts the arm from 0 to 90
Its middle fibres are multipennate
6. All of the following structures pass

quadrangular intermuscular space except:
(a)
(b)
(c)
(d)
through
Axillary nerve
Posterior circumflex humeral artery
Posterior circumflex humeral vein
7. Which of the following structures pass through the upper

triangular intermuscular space?
(a)
(b)
(d)
(d)
Anterior circumflex humeral artery

Posterior circumflex humeral artery
8. Which of the following nerves traverse through lower

triangular intermuscular space:
(a)
(b)
(c)
(d)
Axillary nerve
Radial nerve
Median nerve
Answers
1. d, 2. a, 3. b, 4. c, 5. c, 6. b, 7. d, 8. c
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CHAPTER 6
1. All of the following statements about sternoclavicular
joint are true except:
(a)
(b)
(c)
(d)
It is a saddle type of synovial joint

Its articular surfaces are covered with fibrocartilage
It is frequently involved in dislocation
Its joint cavity is divided into two parts by an articular
disc
2. Musculotendinous cuff is formed by all the muscles

except:
(a)
(b)
(c)
(d)
Supraspinatus
Teres major
Infraspinatus
Teres minor
3. Anatomically the shoulder joint is most commonly

dislocated:
(a)
(b)
(c)
(d)
Superiorly
Inferiorly
Anteriorly
Posteriorly
4. The synovial bursa which commonly communicates

with the cavity of the shoulder joint is:
(a)
(b)
(c)
(d)
Subscapular bursa
Infraspinatus bursa
Subacromial bursa
None of the above
5. Which of the following nerves is commonly injured in

inferior dislocation of shoulder joint?
(a)
(b)
(c)
(d)
Radial nerve
Ulnar nerve
Axillary nerve
6. Shoulder movements occur at:

(a)
(b)
(c)
(d)
(e)
Glenohumeral joint only

Sternoclavicular joint only
Acromioclavicular joint only
Scapulothoracic joint only
All of the above joints
7. Which of the following structures prevent superior

dislocation of head of humerus?
(c) Glenohumeral joint

(d) Scapulothoracic joint
9. The term shoulder separation is used for:

(a)
(b)
(c)
(d)
Dislocation of shoulder joint

Dislocation of acromioclavicular joint
Dislocation of sternoclavicular joint
None of the above
Answers
1. c, 2. b, 3. b, 4. a, 5. d, 6. e, 7. c, 8. c, 9. b
CHAPTER 7
1. The group of spinal segments supplying cutaneous
innervation to upper limb is:
(a)
(b)
(c)
(d)
C5 to T1
C4 to C8
C3 to T3
C4 to T2
2. The spinal segment providing dermatomal supply to

the little finger is:
(a)
(b)
(c)
(d)
C4
T4
C8
C6
3. All of the following structures are present in the deltopectoral groove except:
(a)
(b)
(c)
(d)
Cephalic vein
Deltopectoral lymph node
Basilic vein
Deltoid branch of thoraco-acromial artery
4. The lymph vessels from thumb drain into which group

of axillary lymph nodes:
(a)
(b)
(c)
(d)
Anterior
Posterior
Central
Lateral
5. Most commonly used vein for intravenous injection is:

(a)
(b)
(c)
(d)
Cephalic vein
Basilic vein
Median cubital vein
Median vein of the forearm
Coracohumeral ligament
Coracoacromial arch
Transverse humeral ligament
6. Which of the following statements about cephalic vein is

incorrect?
8. Chief articulation of shoulder is:
(a) Cephalic vein corresponds to the great saphenous
(a)
(b)
(c)
(d)
(a) Sternoclavicular joint

(b) Acromioclavicular joint
vein of the lower limb

(b) It is the postaxial vein of the upper limb
(c) It pierces clavipectoral fascia to drain into axillary
vein
(d) Greater part of its blood is drained into basilic vein
through median cubital vein
7. Select the incorrect statement about the basilic vein:
(a) It is the postaxial vein of the upper limb
(b) It begins form the medial end of the dorsal venous
plexus
(c) It continues upwards as axillary vein at the upper
border of teres major

(d) It is accompanied by medial cutaneous nerve of the
forearm
8. All of the following cutaneous nerves are derived from
radial nerve except:
(a)
(b)
(c)
(d)
Lower lateral cutaneous nerve of arm

Upper lateral cutaneous nerve of arm
Superficial terminal branch of radial nerve
Posterior cutaneous nerve of arm
Answers
1. c, 2. c, 3. c, 4. d, 5. c, 6. b, 7. c, 8. b
(b) Ulnar
(c) Radial
(d) Musculocutaneous
5. Which of the following muscles is innervated by both

musculocutaneous and radial nerve?
(a)
(b)
(c)
(d)
Biceps brachii
Coracobrachialis
Brachialis
Brachioradialis
6. Select the incorrect statement about the coracobrachialis:

(a) It arises from tip of coracoid process of scapula
(b) It has more morphological than functional
significance
(c) The ligament of Struthers represents its third head
(d) It is pierced by ulnar nerve
7. All of the following are branches of brachial artery

except:
(a)
(b)
(c)
(d)

Main humeral nutrient artery
Radial collateral artery
Superior ulnar collateral artery
CHAPTER 8
1. The all of following muscles are present in the anterior
compartment of the arm except:
(a)
(b)
(c)
(d)
Brachialis
Brachioradialis
Coracobrachialis
Biceps brachii
2. The only muscle of anterior compartment of arm that

is inserted into the humerus is:
(a)
(b)
(c)
(d)
Biceps brachii
Coracobrachialis
Brachialis
None of the above
3. All transitions which occur at the level of insertion of

coracobrachialis are correct except:
(a) Median nerve crosses brachial artery from lateral to
medial side
(b) Ulnar pierces medial intermuscular septum to enter
the posterior compartment of the arm
(c) Cephalic vein pierces the deep fascia
(d) Radial nerve pierces the lateral intermuscular
septum to enter the anterior compartment of the
arm
4. The nerve that lies in the groove behind the medial
epicondyle of humerus is:
(a) Median
8. Select the incorrect statement about the biceps brachii

muscle:
(a) It normally has two heads
(b) Its long head arises from infraglenoid tubercle of
scapula
(c) It is capable of affecting movements at glenohumeral,
elbow and superior radio-ulnar joints

(d) It is supplied by musculocutaneous nerve
Answers
1. b, 2. b, 3. c, 4. b, 5. c, 6. d, 7. c, 8. b
CHAPTER 9
1. All of the following are superficial muscles on the front
of forearm except:
(a)
(b)
(c)
(d)

Pronator teres
Palmaris longus
2. Select the incorrect statement about the pronator teres:

(a) It is the smallest superficial flexor of the forearm
(b) Its medial border forms the medial boundary of
cubital fossa
(c) Median nerve passes between its two heads
(d) Ulnar nerve is separated from median nerve by its
deep head
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316
3. The radial artery on the front of wrist lies lateral to the

tendon of:
(a)
(b)
(c)
(d)
Brachioradialis
4. The anterior interosseous nerve is a branch of:

(a)
(b)
(c)
(d)
Superficial branch of radial nerve

Deep branch of radial nerve
Median nerve
Ulnar nerve
5. All of the following deep muscles on the back of the

forearm outcrop in the distal third of the forearm
except:
(a)
(b)
(c)
(d)

6. All of the following structures pass through the fourth

compartment of extensor retinaculum on the dorsal
aspect of wrist except:
(a)
(b)
(c)
(d)
Extensor digitorum
7. The supinator muscle is supplied by

(a)
(b)
(c)
(d)
Ulnar nerve
Median nerve
8. Which of the following statements is not correct?

(a) Ulnar nerve passes between the two heads of flexor
carpi ulnaris
(b) Median nerve passes between the two heads of
pronator teres
(c) Median nerve passes between the two head of flexor
(d) Radial nerve passes between the two heads of flexor
Answers
1. d, 2. b, 3. c, 4. c, 5. b, 6. b, 7. d, 8. d
CHAPTER 10
1. Select the incorrect statement about the elbow joint:
(a) It is a hinge type of synovial joint
(b) It consists of two articulations, humero-radial and
humero-ulnar
(c) It usually dislocates anteriorly

(d) Effusion within joint cavity distends elbow posteriorly
2. Medial collateral ligament of elbow joint is closely

related to:
(a)
(b)
(c)
(d)
Radial nerve
Ulnar artery
Ulnar nerve
Median nerve
3. Clinically most important synovial bursa around elbow

joint is:
(a)
(b)
(c)
(d)
Subtendinous olecranon bursa

Subcutaneous olecranon bursa
Bicipitoradial bursa
Bursa between biceps tendon and oblique cord
4. Select the incorrect statement about superior radio-ulnar

joint:
(a) It is a pivot type of synovial joint
(b) Its cavity does not communicate with the cavity of
elbow joint
(c) It permits movements of supination and pronation
(d) Its prime stabilizing factor is its annular ligament
5. Nerve entrapments which occur around the elbow

include all except:
(a)
(b)
(c)
(d)
Median nerve entrapment

Ulnar nerve entrapment
Radial nerve entrapment
Posterior interosseous nerve entrapment
6. Select the incorrect statement about the inferior radioulnar joint:

(a) It is a pivot type of synovial joint
(b) Its cavity communicates with the cavity of wrist
joint
(c) Its prime stability is provided by its articular disc
(d) It permits supination and pronation of forearm
7. Select the incorrect statement about the interosseous

membrane of the forearm:
(a) It is a fibrous membrane which stretches between
interosseous border of radius and ulna

(b) Its fibres run downwards and laterally from ulna to
the radius
posterior surface is related to anterior
interosseous artery and posterior interosseous nerve
(d) Its anterior surface is related to anterior interosseous
artery and anterior interosseous nerve
(c) Its
8. All are correct statements about oblique cord of forearm

except:
(a) It is fibrous band extending between radial and
ulnar tuberosities
(b) Its fibres are directed opposite to those of
(c) Posterior interosseous nerve enters the back of
forearm through gap between oblique cord and
(d) Morphologically it represents the degenerated part
of the flexor pollicis longus
Answers
1. c, 2. c, 3. b, 4. b, 5. a, 6. b, 7. b, 8. c
CHAPTER 11
1. Select the incorrect statement about the palmaris brevis
muscle:
(a) It is subcutaneous muscle
(b) It arises from flexor retinaculum and palmar
aponeurosis
(c) It is innervated by median nerve
(d) Its contraction causes wrinkling of medial palmar
skin
2. All of the following structures pass superficial to the
flexor retinaculum except:
(a)
(b)
(c)
(d)
Ulnar nerve
Tendon of palmaris longus
Ulnar artery
3. All the structures pass through carpal tunnel except:

(a)
(b)
(c)
(d)
Tendons of flexor digitorum superficialis

Tendon of flexor digitorum profundus
Tendon of flexor carpi radialis
Tendon of flexor pollicis longus
(c) Space of Parona

(d) None of the above
7. Radial bursa is the synovial sheath enclosing the tendon

of:
(a)
(b)
(c)
(d)

8. All the statements about the palmar interossei are

correct except:
(a)
(b)
(c)
(d)
They are unipennate

They take origin from all the five metacarpals
They are innervated by ulnar nerve
They adduct the digits
9. All the statements about ulnar bursa are correct except:

(a) It encloses tendons of flexor digitorum superficialis
and flexor digitorum profundus

(b) It communicates with the digital synovial sheath of
little finger
(c) Distally it extends in the palm up to the heads of
metacarpals
(d) Proximally it extends into the forearm about a finger
breadth above the flexor retinaculum
10. Select the incorrect statement about the superficial
palmar arterial arch:
(a)
(b)
(c)
(d)
It is a direct continuation of ulnar artery

It lies proximal to the deep palmar arch
It lies deep to the palmar aponeurosis
It lies superficial to long flexor tendons
Answers
1. c, 2. b, 3. c, 4. d, 5. d, 6. a, 7. b, 8. b, 9. c, 10. b
4. Select the true statement about the abductor pollicis:

(a)
(b)
(c)
(d)
It is the muscle of thenar eminence

It is a content of thenar space
It transmits ulnar artery between its two heads
It is innervated by ulnar nerve
5. Select the incorrect statement about an anatomical

snuff-box:
(a) It is bounded posteromedially by the tendon of
flexor pollicis longus

(b) Its roof is crossed by cephalic vein
(c) Pulsations of radial artery can be felt in its floor
(d) Tenderness in the anatomical snuff-box indicates
fracture of capitate bone

6. First lumbrical canal is a diverticulum of:
(a) Thenar space
(b) Midpalmar space
CHAPTER 12
1. Select the incorrect statement about the wrist joint:
(a)
(b)
(c)
(d)
It is a synovial joint of saddle variety

It is a synovial joint of ellipsoid variety
Ulna does not take part in this articulation
Its cavity does not communicate with the cavity of
inferior radio-ulnar joint
2. Select the incorrect statement about the wrist joint:

(a) Its upper articular surface is formed by radius and
ulna
(b) Its lower articular surface is formed by scaphoid,
lunate and triquetral bones

(c) It is an ellipsoidal joint
(d) It permits free rotatory movements
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318
3. All of the following bones form the proximal row of

carpal bones except:
(a)
(b)
(c)
(d)
Lunate
Pisiform
Trapezium
Scaphoid
3. All the statements about superficial radial nerve are

true except:
4. All the carpometacarpal joints are plane type of synovial

joint except:
(a)
(b)
(c)
(d)
First carpometacarpal
Second carpometacarpal
Third carpometacarpal
Fourth carpometacarpal
5. All are the features of position of rest of hand except:

(a)
(b)
(c)
(d)
Forearm is in semiprone position

Wrist joint is slightly extended
Fingers are partially flexed
Plane of thumb-nail lies parallel to the plane of
finger-nails
6. Flexion of thumb is produced by all muscles except:

(a)
(b)
(c)
(d)

Opponens pollicis
7. The following muscles cause abduction of wrist except:

(a)
(b)
(c)
(d)

8. Which finger is not abducted by dorsal interossei:

(a)
(b)
(c)
(d)
(b) Palmar cutaneous branch of ulnar nerve

(c) Recurrent branch of ulnar nerve
(d) None of the above
Second
Third
Fourth
Fifth
Answers
1. a, 2. a, 3. c, 4. a, 5. d, 6. c, 7. d, 8. d
CHAPTER 13
1. Select the incorrect statement about the radial nerve:
(a) It arises from posterior cord of the brachial plexus
(b) It gives lateral and posterior cutaneous nerves of
arm in spiral groove

(c) It supplies flexor carpi radialis
(d) Its lesion in radial groove causes wrist drop
2. Skin over the thenar eminence is supplied by:
(a) Palmar cutaneous branch of median nerve
(a)
(b)
(c)
(d)
It arises from radial nerve in the spiral groove

It is entirely sensory
It arises from radial nerve in cubital fossa
It provides sensory innervation to skin on the root
of thumb
4. Which of the following statements is incorrect?

(a)
(b)
(c)
(d)
Median nerve is called laborers nerve

Ulnar nerve is called musicians nerve
Ulnar nerve in the hand is called eye of the hand
Median nerve in the hand is called eye of the
hand
5. Sensory innervation to the skin on the dorsum of hand

is provided by:
(a)
(b)
(c)
(d)
Radial nerve
Median nerve
Ulnar nerve
All of the above
6. The ape-thumb deformity occurs due to lesion of:

(a)
(b)
(c)
(d)
Radial nerve
Median nerve
Ulnar nerve
7. All are signs of ulnar nerve lesion except:

(a)
(b)
(c)
(d)
Wasting of hypothenar eminence

Loss of abduction and adduction of fingers
Absence of flexion of ring and little fingers
Absence of flexion of index finger
8. A median nerve palsy causes all of the following signs

except:
(a)
(b)
(c)
(d)
Wasting of thenar eminence

Loss of opposition of thumb
Pointing index finger
Loss of sensation on the palmar aspect of medial 1
fingers
9. Forearm has all of the following cutaneous nerves

except:
(a)
(b)
(c)
(d)
Lateral cutaneous nerve of forearm

Medial cutaneous nerve of forearm
Anterior cutaneous nerve of forearm
Posterior cutaneous nerve of the forearm
Answers
1. c, 2. c, 3. a, 4. c, 5. d, 6. b, 7. d, 8. d, 9. c
CHAPTER 14
1. Select the incorrect statement about the thoracic inlet:
(a)
(b)
(c)
(d)
It communicates with the root of the neck

It is roofed on either side by suprapleural membrane
It is circular in shape
Its plane slops downwards and forwards
(b) Medial arcuate ligament

(c) Aortic opening
(d) Lateral arcuate ligament
Answers
1. c, 2. b, 3. c, 4. c, 5. b, 6. d, 7. d, 8. b
CHAPTER 15
2. All the statements about Sibsons fascia are correct

except:
1. Select the incorrect statement about the manubrium

sterni:
(a) Forms the diaphragm of thoracic inlet

(b) Its apex is attached to the tip of the transverse
(a) It is the thickest and strongest part of the sternum

(b) It is the commonest site for bone marrow aspiration
(c) It articulates below with body of sternum to form
process of T1 vertebra
(c) Its base is attached to the inner border of the 1st rib
(d) It protects the underlying cervical pleura
3. All of the following nerves pass through thoracic inlet

except:
(a)
(b)
(c)
(d)
Right and left phrenic nerves

Right and left first thoracic nerves
Right and left recurrent laryngeal nerves
Right and left vagus nerves
4. Which of the following structures does not pass through

the aortic orifice of the diaphragm?
(a)
(b)
(c)
(d)
Aorta
Thoracic duct
Hemiazygos vein
Azygos vein
5. Caval opening of diaphragm lies at the level of:

(a)
(b)
(c)
(d)
Body of T6 vertebra
Body of T8 vertebra
Body of T10 vertebra
Body of T12 vertebra
6. Congenital posterolateral defect of diaphragm occurs

due to failure of development of:
(a)
(b)
(c)
(d)
Mesoderm of body wall

Dorsal mesentery of esophagus
Septum transversum
Pleuroperitoneal membrane
7. All of the following structures pass through the crura of

diaphragm except:
(a)
(b)
(c)
(d)
Greater splanchnic nerve

Lesser splanchnic nerve
Hemiazygos vein
Sympathetic chain
8. Sympathetic chain enters the abdomen by passing deep

to:
(a) Median arcuate ligament
primary cartilaginous joint

(d) Upper part of its posterior surface is related to the
arch of aorta
2. All the statements about the sternal angle are correct
except:
(a) It is formed by the articulation of the manubrium
with the body of the sternum

(b) It lies at the level of 2nd costal cartilage
(c) It lies opposite the intervertebral disc between the
T3 and T4 vertebrae
(d) Ascending aorta ends at this level
3. All are the atypical ribs except:

(a)
(b)
(c)
(d)
1st rib
2nd rib
9th rib
10th rib
4. Anterior aspect of the neck of 1st rib is related to all

structures except:
(a)
(b)
(c)
(d)
Sympathetic chain
Superior intercostal vein
Superior intercostal artery
Ventral ramus of first thoracic nerve
5. Select the incorrect statement about the 12th thoracic

vertebrae:
(a)
(b)
(c)
(d)
It appears like first lumbar vertebra

Its transverse process presents three tubercles
Its transverse process has small articular facet
Its body presents circular articular facet on each side
6. First costosternal/chondrosternal joint is a:

(a)
(b)
(c)
(d)
Synovial joint
Primary cartilaginous joint
Secondary cartilaginous joint
Fibrous joint
7. The rib commonly fractures:

(a) At its posterior angle
319
320
(b) At the middle of its shaft

(c) At its neck
(d) At its anterior angle
8. All are the atypical features of 1st rib except:

(a)
(b)
(c)
(d)
Its shaft has upper and lower surfaces

Its angle and tubercle coincide
Its head bears two articular facets
It is the most curved rib
7. During quiet respiration, the elevation of ribs is done

mostly by the contraction of:
(a)
(b)
(c)
(d)
Internal intercostal muscles

Intercostalis intimi muscles
Subcostalis muscles
8. Select the incorrect statement about the increase in

various diameters of thoracic cavity
(a) Pump-handle movement of sternum increases its
Answers
1. c, 2. c, 3. c, 4. b, 5. c, 6. b, 7. a, 8. c
CHAPTER 16
1. Which of the following muscles is attached on the inner
aspects of the ribs?
(a)
(b)
(c)
(d)
External intercostal
Internal intercostal
Intercostalis intimus
None of the above
2. Anterior intercostal membrane is the continuation of:

(a)
(b)
(c)
(d)
External intercostal muscle

Internal intercostal muscle
Intercostalis intimi muscle
Subcostalis muscle
3. All of the following are parts of transverse thoracis

muscle except:
(a)
(b)
(c)
(d)
Intercostalis intimus
Subcostalis
Levatores costarum
Sternocostalis
4. Typical intercostal nerves are:

(a)
(b)
(c)
(d)
3rd to 6th intercostal nerves

7th to 11th intercostal nerves
7th to 10th intercostal nerves
1st and 2nd intercostal nerves
5. The branches of all of the following arteries supply blood

to intercostal spaces except:
(a)
(b)
(c)
(d)

Internal thoracic artery
Superior epigastric artery
Musculophrenic artery
6. Increase in vertical diameter of thoracic cavity is brought

about by:
(a)
(b)
(c)
(d)
Pump-handle movement of the sternum

Bucket-handle movement of the ribs
Contraction of diaphragm
(a) and (b)
anteroposterior diameter
(b) Contraction of diaphragm increases its vertical
diameter
(c) Bucket-handle movement of ribs increases its
transverse diameter
(d) Pump-handle movement of sternum increases its
vertical diameter
Answers
1. c, 2. a, 3. c, 4. a, 5. c, 6. c, 7. b, 8. d
CHAPTER 17
1. Select the incorrect statement about the parietal pleura:
(a)
(b)
(c)
(d)
It develops from somatopleuric mesoderm

It is supplied by somatic nerves
It develops from splanchnopleuric mesoderm
It is sensitive to pain and touch
2. All the statements about visceral pleura are correct except:

(a)
(b)
(c)
(d)
It develops from splanchnopleuric mesoderm

It is innervated by autonomic nerves
It lines the thoracic wall
It is insensitive to touch and temperature
3. Pleura extends beyond the thoracic cage on all of the

following sites except:
(a)
(b)
(c)
(d)
Root of the neck

Costovertebral angles
Right xiphisternal angle
Left xiphisternal angle
4. Select the incorrect statement about the summit of

cervical pleura:
(a)
(b)
(c)
(d)
It lies 2.5 cm above the medial end of the clavicle

It lies 2.5 cm above the 1st costal cartilage
It lies 5 cm above the 1st costal cartilage
It is covered by Sibsons fascia
5. In the midaxillary line the inferior margin of parietal

pleura crosses:
(a)
(b)
(c)
(d)
6th rib
8th rib
10th rib
12th rib
6. All arteries supply the pleura except:

(a)
(b)
(c)
(d)
5. Nutrition to the nonrespiratory portions of lung is

supplied by:
Internal thoracic
Intercostal
Bronchial
Pulmonary
7. Select the incorrect statement about the pulmonary

ligament:
(a) It is a fold of the visceral pleura
(b) It provides a dead space for expansion of pulmonary
veins
(c) It extends from root of lung as far down as
diaphragm
(d) It extends between mediastinum and the lung
8. Select the incorrect statement
costodiaphragmatic recess:
about
the
(a) It is the lower part of pleural cavity between the
diaphragmatic and costal pleura

(b) It is the least dependent part of the pleural cavity
(c) It lies 89 cm deep in the midaxillary line
(d) It lies 2.5 cm deep in the midclavicular line
Answers
1. c, 2. c, 3. d, 4. b, 5. c, 6. d, 7. a, 8. b
CHAPTER 18
1. Mediastinal surface of right lung is related to all except:
(a)
(b)
(c)
(d)
Right atrium
Arch of aorta
Arch of azygos vein
Inferior vena cava
2. Mediastinal surface of the left lung is related to all

except:
(a)
(b)
(c)
(d)
Left ventricle
Ascending aorta
Superior vena cava
Arch of aorta
3. Uppermost structure in the hilum of right lung is:

(a)
(b)
(c)
(d)
Pulmonary artery
Superior pulmonary vein
Bronchus
Bronchial artery
4. During quiet respiration the posterior end of lower

border of lung passes across:
(a)
(b)
(c)
(d)
6th rib
8th rib
10th rib
T12 spine
(a)
(b)
(c)
(d)
Pulmonary artery
Pulmonary vein
Bronchial artery
(a) and (c)
6. All are characteristic features of a bronchopulmonary

segment except:
(a)
(b)
(c)
(d)
It is pyramidal in shape
It is aerated by a tertiary bronchus
It has its own segmental vein
It is surrounded by the connective tissue
7. Number of bronchopulmonary segments in lower lobe

of each lung is:
(a)
(b)
(c)
(d)
Two
Three
Four
Five
8. The lingula is a tongue-shaped projection from:

(a)
(b)
(c)
(d)
Upper lobe of right lung

Upper lobe of left lung
Lower lobe of right lung
Lower lobe of left lung
Answers
1. b, 2. c, 3. c, 4. c, 5. c, 6. c, 7. d, 8. b
CHAPTER 19
1. All are correct statements about mediastinum except:
(a) It is broad septum within thoracic cavity, which
separates two pleural cavities

(b) It contains all the thoracic viscera and structures
except lungs
(c) Structures
forming mediastinum are bound

together by loose connective tissue
(d) It is rigid and nonmovable septum in living people
2. All form the boundaries of superior mediastinum
except:
(a)
(b)
(c)
(d)
Manubrium sterni
Upper four thoracic vertebrae
Diaphragm
Plane of superior thoracic aperture
3. All are contents of superior mediastinum except:

(a)
(b)
(c)
(d)
Arch of aorta
Pulmonary trunk
Superior vena cava
321
322
4. All structures traverse the whole length of mediastinum

except:
(a)
(b)
(c)
(d)
Esophagus
Trachea
Thoracic duct
Sympathetic trunks
5. All are contents of middle mediastinum except:

(a)
(b)
(c)
(d)
Heart
Pulmonary arteries
Brachiocephalic veins
Pulmonary veins
6. All the statements regarding posterior mediastinum are

correct except:
(a) Pus in the posterior mediastinum can enter the
thighs
(b) Neck infection behind prevertebral layer of deep
cervical fascia cannot extend into the posterior

mediastinum
(c) Neck infection in the retropharyngeal space can
extend into the posterior mediastinum
(d) Its superior boundary is formed by superior thoracic
aperture
7. Posterior mediastinum provides passage to all structures
except:
(a)
(b)
(c)
(d)
Esophagus
Trachea
Azygos veins
8. The thymus is located in:

(a)
(b)
(c)
(d)
Middle mediastinum
Posterior mediastinum
Anterior mediastinum
Answers
1. d, 2. c, 3. b, 4. b, 5. c, 6. d, 7. b, 8. a
CHAPTER 20
(c) It lies behind the ascending aorta and pulmonary
trunk
(d) It lies in front of ascending aorta and pulmonary
trunk
3. Sternocostal surface of the heart is mainly formed by:
(a)
(b)
(c)
(d)
4. Apex beat in adults is normally felt in the:

(a) Left 4th intercostal space in the midclavicular line
(b) Left 5th intercostal space just medial to the
midclavicular line
(c) Left 6th intercostal space just medial to the
midclavicular line
(d) Left 3rd intercostal space just lateral to the
midclavicular line
5. Select the incorrect statement about the oblique
pericardial sinus:
(a)
(b)
(c)
(d)
Fibrous pericardium and serous pericardium

Fibrous pericardium and epicardium
Parietal pericardium and visceral pericardium
Epicardium and myocardium
2. Select the correct statement about the transverse

pericardial sinus:
(a) It lies in front of superior vena cava
(b) It lies in front of pulmonary veins
It is the recess of serous pericardium

It lies behind the left atrium
It lies behind the right atrium
It is closed on all sides except below
6. All the statements are correct about the conducting

system of the heart except:
(a) It is made up of specialized cardiac muscle fibres
(b) It is responsible for initiation and conduction of
impulses
(c) Nearly whole of the conducting system is supplied
by left coronary artery

(d) Its SA node is known as the pacemaker of the heart
7. Select the incorrect statement about the area of

superficial cardiac dullness:
(a)
(b)
(c)
(d)
1. Pericardial cavity lies between:

(a)
(b)
(c)
(d)
Right atrium
Right ventricle
Left ventricle
(a) and (b)
It lies in front of right ventricle

It is related to the left 4th and 5th intercostal spaces
It is covered by lung and pleura
It can be used as a site of aspiration of fluid in
pericardial effusion
8. The base of the heart is formed by:

(a)
(b)
(c)
(d)
Right and left ventricles

Right and left atria
Right atrium and right ventricle
Left atrium and left ventricle
9. All structures meet at the crux of the heart except:

(a) Posterior interventricular groove
(b) Posterior atrioventricular groove
(c) Interatrial groove

(d) Sulcus terminalis
10. Most anteriorly located valve of the heart is:

(a)
(b)
(c)
(d)
7. All are correct statements about pulmonary trunk except:

(a)
(b)
(c)
(d)
Pulmonary
Aortic
Tricuspid
Bicuspid
11. Conducting system of the heart is a modification of:

(a)
(b)
(c)
(d)
(c) Subcostal arteries

(d) Left bronchial arteries
Epicardium
Myocardium
Endocardium
None of the above
Answers
1. c, 2. c, 3. d, 4. b, 5. c, 6. c, 7. c, 8. b, 9. d, 10. a, 11. b
CHAPTER 21
1. All the statements about SVC are correct except:
(a) It lies both in superior and middle mediastina
(b) It is devoid of valves
(c) It is formed at the lower border of the right 1st
costal cartilage
(d) It pierces pericardium at the level of the right 2nd
costal cartilage
It is about 5 cm long
It arises from the infundibulum of the right ventricle
Its termination lies in front of the arch of aorta
It is completely enclosed within the fibrous
pericardium
8. Select the incorrect statement about the pulmonary

trunk:
(a) It is completely enclosed within the fibrous
pericardium
(b) It along with ascending aorta is enclosed by a
common sheath of visceral pericardium
(c) It is intimately related to the two coronary arteries
(d) It lies entirely to the right of ascending aorta
9. Aortic knuckle, a projection in the upper part of left
margin of the cardiac shadow in x-ray chest PA view, is
cast by:
(a)
(b)
(c)
(d)
Ascending aorta
Arch of aorta
Aortic sinuses
Descending aorta
Answers
1. d, 2. c, 3. d, 4. d, 5. b, 6. a, 7. c, 8. d, 9. b
2. All are the tributaries of SVC except:

(a)
(b)
(c)
(d)

Hemiazygos vein
Azygos vein
3. All the statements regarding SVC are correct except:

(a)
(b)
(c)
(d)
It is 7 cm long and 2 cm wide

It has no valves
Its lower half is covered by pericardium
It is completely enclosed in the pericardium
4. The ascending aorta gives origin to:

(a)
(b)
(c)
(d)
Right and left coronary arteries
5. All are the branches of arch of aorta except:

(a)
(b)
(c)
(d)
Right common carotid artery
6. All are the branches of descending thoracic aorta except:

(a) Superior intercostal arteries
(b) Posterior intercostal arteries
CHAPTER 22
1. Select the incorrect statement about the esophagus:
(a)
(b)
(c)
(d)
It is narrowest at its commencement

It is about 15 cm long
It ends at the level of T11 vertebra
It pierces diaphragm at the level of T10 vertebra
2. Constrictions of esophagus are present at all sites

except:
(a)
(b)
(c)
(d)
At cricopharyngeal junction
Where it is crossed by the arch of aorta
Where it is surrounded by right crus of diaphragm
Where it is crossed by the left principal bronchus
3. Select the incorrect statement about the distances of

constrictions in esophagus from upper incisor teeth:
(a)
(b)
(c)
(d)
First constriction is 6 inches

Second constriction is 9 inches
Third constriction is 11 inches
Fourth constriction is 17 inches
4. Lymphatics from the lower end of esophagus drains

into:
(a) Deep cervical lymph nodes
323
324
(b) Pretracheal lymph nodes

(c) Posterior mediastinal lymph nodes
(d) Celiac lymph nodes
5. Esophagus is supplied by the esophageal branches of all

the arteries except:
(a)
(b)
(c)
(d)
Inferior thyroid
Left gastric
Right gastric
6. All statements regarding trachea are true except:

(a) It begins in the neck at the lower border of cricoid
cartilage
(b) It is about 20 cm long
(c) It is made up of 1620 C-shaped hyaline cartilages
(d) It terminates in the thorax at the level of sternal
angle
7. Select the incorrect statement about the trachea:
(a) It is flexible fibro-elastic tube
(b) It extends from lower border C6 vertebra to the
lower border of T4 vertebra

(c) Its external diameter in an adult male is about 2 cm
(d) Its internal diameter in an adult male is 15 mm
3. All structures lie behind the thoracic duct at the root of

the neck except:
(a)
(b)
(c)
(d)
Vertebral artery and vein

Carotid sheath
Phrenic nerve
Thyrocervical trunk and its branches
4. All the statements about azygos vein are correct except:

(a) They are paravertebral in position
(b) They are not accompanied by corresponding
arteries
(c) They have no valves in their lumen
(d) They may appear tortuous
5. All are the tributaries of azygos vein except:
(a)
(b)
(c)
(d)
Hemiazygos vein
Right first posterior intercostal vein
Right bronchial vein
6. The left superior intercostal vein drains into:

(a)
(b)
(c)
(d)

Hemiazygos vein
Azygos vein
8. Anteriorly the trachea is related to all structures except:

(a)
(b)
(c)
(d)
Arch of aorta
Esophagus
Deep cardiac plexus
Answers
1. b, 2. a, 3. d, 4. d, 5. d, 6. b, 7. d, 8. c
CHAPTER 23
1. Select the incorrect statement about the thoracic duct:
(a) It begins as an upward continuation of cisterna chyli
(b) It enters the thoracic cavity through an aortic
opening of the diaphragm

(c) It crosses the vertebral column from right to left side
in front of T5 vertebra
(d) It terminates in the external jugular vein
2. All structures form posterior relations of the thoracic
duct in the posterior mediastinum except:
(a) Right posterior intercostal arteries
(b) Terminal parts of hemiazygos and accessory
hemiazygos veins
(c) Esophagus
(d) Vertebral column
7. All the statements regarding accessory azygos vein are

correct except:
(a)
(b)
(c)
(d)
It lies on left side only

It receives left superior intercostal vein
It receives left bronchial veins
It drains into azygos vein
8. Select the incorrect statement about the thoracic

sympathetic trunk:
(a) Its upper end lies in front of the neck of the 1st rib
(b) Its lower end passes behind the medial arcuate
ligament of diaphragm
(c) It commonly possesses 12 ganglia
(d) It lies in front of posterior intercostal nerve and
vessels
9. Regarding thoracic splanchnic nerves, which is the
incorrect statement:
(a)
(b)
(c)
(d)
They consist of preganglionic sympathetic fibres

They are three in number
The lower splanchnic nerve is also called renal nerve
Greater splanchnic nerve arises from 1st to 5th
thoracic ganglia
Answers
1. d, 2. c, 3. b, 4. c, 5. c, 6. d, 7. b, 8. c, 9. d
Index
A
Abscess
axillary, 53
cold, 217218
Achalasia cardia, 299
Anastomosis/anastomoses, arterial
around elbow, 98
around scapula, 51, 70
of coronary, arteries, 275
over acromion, 51
Anatomical snuff box, 157
Aneurysm, aortic, 283
Angioplasty, coronary, 275
Angina pectoris, 275
Angiography, coronary, 275
Aneurysm
arch of aorta, 288
dissecting, 290
Angioplasty, coronary, 275
Angle
carrying, 130
of humeral torsion, 22
of Louis, 34, 211
sternal, 34, 211
subcostal, 211
Annulus ovalis, 265
Aorta, 285
arch of, 286
aneurysm, 286
ascending, 286
coarctation of, 288
descending thoracic, 288
Aortic knuckle, 288
Aortic vestibule, 267, 268
Aperture/apertures
inferior thoracic, 189
superior thoracic, 187
Ape-thumb deformity, 177
Apex beat, 211, 260
Aponeurosis
bicipital, 87, 88
clinical correlation, 141
palmar, 140
Arch, arterial
deep palmar, 149
superficial palmar, 148
Arches of hand, 158
Area of superficial cardiac dullness, 231,
233, 236, 241, 261
Areola, 41
Arm, 92
back of, 89
compartments of, 92
surface landmarks on, 92
contents of anterior
compartment, 93
contents of posterior
compartment, 101
Arrhythmia, 280
Artery/arteries
acromiothoracic, 50
axillary, 49
branches of, 49
relations of, 49
brachial, 86
clinical correlation of, 97
brachiocephalic, 252, 283
coronary
left, 274
right, 273
intercostal, 217
anterior, 220
posterior, 218
internal mammary, 220
internal thoracic, 220
interosseous
anterior, 113
left common carotid, 287
left subclavian, 287
of heart, 273
princeps pollicis, 158
profunda brachii, 102
radial, 113
radialis indicis, 158
sinuatrial, 274
subscapular, 50
superficial palmar, 112, 114
thoracic
aberrant, 113
lateral, 50
superior, 49
thoraco-acromial, 50
ulnar, 112
Arthrodesis, 170
Articularis cubiti, 102
Asthma,
bronchial, 246
AV node, 273
Atrium
left, 266
right, 264
Auricles, of heart, 264, 266
Auscultation
of lung, 241
of sound of cardiac valves, 271
Axilla, 4856
boundaries of, 48
contents of, 49
Axillary nerve, 70
Azygos lobe of lung, 239
Azygos vein, 305
accessory, 309
B
Band, moderator, 266
Barrett, esophagus, 299
Benediction deformity
of hand, 177
Bochdalek, foramen of, 194
Boutonniere deformity, 156
Bone/bones
carpals, 29
clavicle, 10
hamate, 29, 30
humerus, 18
metacarpals, 31
326
Index
of thorax, 196207
phalanges, 32
radius, 23
ribs, 199204
scapula, 15
sesamoid of upper limb, 32
sternum, 196199
thoracic vertebrae, 204207
ulna, 27
Breast, 39
arterial supply, 42
carcinoma of, 44
development of, 45
ligaments of, 41
lymph nodes draining, 42
lymphatic drainage of, 44
lymphatics, 42
venous drainage, 42
Bronchial tree, 241
Bronchioles
respiratory, 243
terminal, 243
Bronchopulmonary segments, 246
Bronchoscopy, 242
Bronchiectasis, 241
Bronchus/bronchi
lobar, 243
principal, 267
segmental, 241
tertiary, 243
Bundle
atrioventricular, 273
of His, 273
Bursa/bursae
infraspinatus, 74
olecranon, 129
radial, 143
subacromial, 74
subscapular, 74
ulnar, 142
Bursitis subacromial, 79
Bypass, coronary, artery, 275
C
Cage, thoracic, 185
rib, 185
Canal, cervico-axillary, 48
Cancer/carcinoma
bronchiogenic, 242
of breast, 44
of esophagus, 300
Cardiac plexuses, 278
deep, 279
superficial, 278
Carina, 294, 301
Cartilage, costal, 207
Catheterization,
pulmonary artery, 290
Cavity/Cavities
pericardial, 257
pleural, 227
thoracic, 185
Cervico-axillary canal, 48
Chordae tendinae, 266
Clavicle, 10
attachments on, 1113
congenital anomalies, 13
fracture, 13
functions, 10
ossification of, 13
side determination, 11
Claw hand, 180, 181
Cleidocranial dysostosis, 13
Coarctation of aorta, 218, 288
Congenital anomalies
of clavicle, 13
of radius, 27
of scapula, 18
Contracture, Dupuytrens, 141
Coopers ligament, 41
Cord, oblique, 134
Costa, 199
Creases, palmar, 138
Crista terminalis, 264
Cuff,
Musculotendinous, 67, 75
rotator, 66, 67, 75
D
Dawbarn sign, 79
Deformity
Claw hand, 180
Madelung, 27
Sprengels deformity of scapula, 18
Dermatomes
of pectoral region, 35
of upper limb, 85
Dermatoglyphics, 138
Development
of breast, 45
of diaphragm, 193
of esophagus, 299
of limbs, 3
of thoracic duct, 305
Dextrocardia, 260
Diaphragm,
development, 193
of thoracic inlet, 188
of thoracic outlet, 189
openings of, 191
thoraco-abdominal, 189
Digital synovial sheaths, 143
Disc, articular
of acromioclavicular joint, 79
of inferior radio-ulnar, 133
of sternoclavicular joint, 79
triangular, 133
Dislocation
of acromioclavicular, 80
of elbow, 130
of shoulder joint, 78
of sternoclavicular joint, 80
Dorsal digital expansion, 156
Duct, thoracic, 302
development, 305
tributaries of, 304
Ductus arteriosus patent, 268
Dullness, superficial cardiac, 231
Dupuytrens contracture, 141
Dysostosis,
clavicular, 13
cleidocranial, 13
Dysphagia, 299
Dyspnea, 246, 270
E
Elbow
golfers, 130
joint, 126
miners, 130
students, 130
tennis, 130
Emphysema
lungs, 244
root of neck, 254
Erbs paralysis, 56
Erbs point, 55
Esophagus, 294300
arterial supply, 298
constrictions, 295
curvatures, 295
lymphatic drainage, 298
microscopic anatomy, 299
nerve supply, 298
parts, 296
venous drainage, 298
Esophagoscopy, 299
Expansion, dorsal digital, 156
F
Fascia
clavipectoral, 38, 39
endothoracic, 228
pectoral, 38
Sibsons, 188
Fibres, Purkinje, 273
Fibrous flexor sheaths, 141
Fibrous pericardium, 256
Finger prints, 138
Fistula
tracheo-esophageal, 299
Foments sign, 144, 181
Index
Foramen
of Bochdalek, 194
of Morgagni, 194
Forearm
back of, 116
deep muscles, 116
superficial muscles, 116
front of
arteries on, 112
muscles on, 106
nerves on, 114
Fossa
cubital, 100
boundaries of, 100
floor of, 100
roof of, 100
ovalis, 265
limbus of, 265
Fracture/s
Bennets, 32
Boxers, 32
Chauffers, 26
Clavicle, 13
Colles, 26
Galeazzi, 29
Monteggia, 29
night stick, 29
of humerus, 22
of scaphoid, 29
Smiths, 26
Frozen shoulder, 78
G
Ganglion/ganglia
stellate, 307
thoracic sympathetic, 307
Girdle, shoulder, 72
pain, 217
Gland
mammary, 39
Grip/grips, 2
Golfers elbow, 130
Gynecomastia, 39, 46
H
Hand, 137159
arteries, 148
back of, 156
intrinsic muscles, 143
movements, 166
nerves of, 150
optimum position at rest, 166
spaces of, 151
surface landmarks on, 137
surgical incisions of, 155
synovial sheaths of, 142
Heart, 260280
apex of, 260
arterial supply, 273
base of, 261
borders of, 261
chambers, 262
crux of, 263
conducting system of, 272
external features, 260
grooves of, 260, 262
lymphatics of, 278
nerve supply of, 278
skeleton of, 272
sounds, 270
sulci of, 262
surfaces of, 261
diaphragmatic, 261
left, 261
sternocostal, 261
valves of, 268270
semilunar, 269
surface marking, 271
venous drainage, 276
Hernia/Hernias
acquired hiatal, 194
diaphragmatic, 194
paraesophageal, 194
posterolateral, 194
sliding, 194
Herpes zoster, 217
Hiccups, 192
His, bundle of, 266, 272
Humerus, 18
attachments, 2922
ossification of, 23
parts, 18
side determination of, 19
surgical neck of, 20
I
Incisions, surgical, of hand, 155
Injury of
axillary nerve, 70
radial nerve, 174
thoracic duct, 304
Intercostal
arteries, 217
lymph nodes, 220
lymph vessels, 220
muscles, 216
nerves, 216
spaces, 215
veins, 220
Intermuscular spaces, 69
lower triangular, 69
quadrangular, 69
upper triangular, 69
J
Joint, joints
acromioclavicular, 79
carpometacarpal, 165
costochondral, 208
costotransverse, 208
costovertebral, 207
elbow, 126
first, 165
glenohumeral, 72
intercarpal, 165
interchondral, 208
intermetacarpal, 165
interphalangeal, 166
intervertebral, 209
manubriosternal, 208
metacarpophalangeal, 166
of thorax, 207209
of hand, 164
radiocarpal, 161
radioulnar, 126
scapulothoracic, 80
shoulder, 72
abduction at, 78, 81
dislocation of, 78
ligaments of, 72
movements of, 76
sternoclavicular, 79
wrist, 161164
movements at, 163
K
Koch, triangle of, 265
Klumpkes paralysis, 56
Knuckle, aortic, 288
Krukenbergs tumor, 44
Kugels artery, 281
L
Langer, foramen of, 39
Larry, space of, 191, 194
Lesion/lesions of
brachial plexus, 55
posterior interosseous nerve, 124
Ligament/ligaments
arcuate, 190
acromioclavicular, 79
annular, 132
Cooper, 41
coracoacromial, 74
coracoacromial arch, 74
coracoclavicular, 79
coracohumeral, 74
glenohumeral, 73
327
328
Index
of axilla, suspensory, 38
pulmonary, 229
quadrate, 132
Struthers, 22
transverse carpal, 139
transverse humeral, 74
Ligamentum nuchae, 59
Limb, upper
bones of, 10
cutaneous nerves of, 83
dermatomes of, 85
evolution of, 1
lymph nodes of, 90
superficial veins of, 86
Limbus fossa ovalis, 265
Line/lines
anterior axillary, 211
midaxillary, 34, 212
midclavicular, 34, 211
midsternal, 34, 211
posterior axillary, 34, 212
scapular, 212
Lingula of lung, 235
Lowers intervenous tubercle, 265
Lung, 234247
arterial supply of, 244
differences between right
and left, 240
external features, 234
fissures of, 237
lobes of, 237
relations of mediastinal surface, 237
root of, 239
surface marking of, 240
venous drainage of, 244
Lymph nodes
axillary, 53
bronchomediastinal, 245
bronchopulmonary, 245
hilar, 245
tracheobronchial, 245
M
Madelung deformity, 27
Mallet, nger, 156
Mammary gland, 39
Mammogram, 45
Marshall, vein of, 276
Mediastinitis, 254
Mediastinum, 227, 249254
anterior, 253
contents of, 249
divisions, 251
middle, 253
posterior, 253
superior, 251
Membrane interosseous, 133

suprapleural, 188
Montgomerys tubercles, 41
Movements
respiratory, 225
Muscle/muscles
abductor digiti minimi, 146
abductor pollicis brevis, 146
abductor pollicis longus, 120
abductor pollicis, 144
anconeus, 118
articularis cubiti, 102
biceps brachii, 93
boxers muscle, 38
brachialis, 195
brachioradialis, 118
coracobrachialis, 94
changes at level of insertion, 95
morphology of, 94
deltoid, 65, 92
diaphragm, 189
development, 193
extensor carpi radialis brevis, 118
extensor carpi radialis
longus, 118
extensor carpi ulnaris, 118
extensor digiti minimi, 118
extensor digitorum, 118
extensor indicis, 120
extensor pollicis brevis, 120
extensor pollicis longus, 120
flexor carpi radialis, 107
flexor carpi ulnaris, 108
flexor digiti minimi, 146
flexor digitorum profundus, 110
flexor digitorum sublimis, 109
flexor digitorum superficialis, 109
flexor pollicis brevis, 146
flexor pollicis longus, 110
hypothenar, 144
infraspinatus, 66
intercostal, 213, 216
actions of, 216
external, 214
internal, 214
intercostalis intimi, 216
interossei,
dorsal, 147
palmar, 147
intrinsic of hand, 143
latissimus dorsi, 61
levator scapulae, 61
levatores costarum, 215
lumbricals of hand, 144
opponens digiti minimi, 146
opponens pollicis, 146
palmaris brevis, 139
palmaris longus, 108

papillary, 266
pectoralis major, 35
pectoralis minor, 36
pronator quadratus, 111
pronator teres, 106
rhomboideus major, 62
rhomboideus minor, 62
serratus anterior, 38
sternocostalis, 215
subclavius, 37
subcostalis, 214
subscapularis, 66
supinator, 120, 122
supraspinatus, 65
teres major, 66
teres minor, 66
thenar, 144
trapezius, 60
triceps, 101
Musculi pectinati, 264
Musculocutaneous nerve, 96, 172
Myocardial infarction, 275
N
Nerve/nerves
axillary, 70, 172
greater splanchnic, 307
in front of forearm, 98
in the palm, 150
interosseous
anterior, 134
posterior, 123
laborers, 177
least splanchnic, 307
lesser splanchnic, 307
lowest splanchnic, 307
median, 150, 175
musculocutaneous, 96, 172
musicians, 180
palmar digital, 177
radial, 173
ulnar, 150, 178
in hand, 151
Node
AV, 273
SA, 273
of Keith Flack, 272
of Tawara, 273
sinuatrial, 272
Notch/notches
jugular, 34
suprasternal, 34, 211
Index
O
Oblique sinus pericardium, 258
Omovertebral body, 18
Opponens pollicis, 146
Ossification
of carpal bone, 30, 31
of clavicle, 13
of humerus, 23
of radius, 26
of ulna, 29
deep, 278
superficial, 278
Pneumonia
aspiration, 246
Pneumothorax, 254, 255
Potts disease, 217
Pronation, 134
Pulled elbow, 130
Pulmonary units, 244
Pulmones, 234
R
P
Pacemaker, of heart, 273
Pain, shoulder tip, 82
Palm, 137
flexion creases, 138
Pancoast syndrome, 235
Paracentesis thoracis, 218
Paralysis
Erbs, 56
Klumpkes, 56
of diaphragm, 192
peau dorange, 44
Pericardial effusion, 259
Pericardiocentesis, 259
Pericarditis, 259
Pericardium, 256259
cavity, pericardial, 257
contents, 257
differences between parietal and
serous, 257
fibrous, 256
oblique sinus of, 258
serous, 257
sinuses of, 257
transverse sinus of, 257
transverse, 257
Subdivisions, 256
Phalens test, 178
Pleura, 228
blood supply of, 232
cervical, 230
costal, 228
mediastinal, 228
parietal, 228
pulmonary, 228
recesses of, 231
surface marking of, 230
visceral, 228
Pleural effusion, 231, 232
Pleuritis, 232
Pleurisy, 232
Plexus
brachial, 53
cardiac, 278
Radius, 23
attachments on, 23
Referred pain
cardiac, 279
diaphragm, 308
esophagus, 298
girdle pain, 217
pleura, 231
root pain, 217
Region
pectoral, 34
surface landmarks of, 34
scapular, 63
Relation/s
mediastinal surface of lung, 236-237
Respiration, mechanism of, 222225
pump handle movement, 223
bucket handle movement, 224
types, 225
Retinaculum
extensor, 117
flexor, 105, 139
Rib/ribs, 199204
arrangement, 199
atypical, 201
cervical, 204
classification, 199
eleventh, 202
first, 201
floating, 199
Gorilla, 204
second, 202
tenth, 202
typical, 202
twelfth, 202
Ring, fibrous, 269, 272
Rotator cuff, 67
Rupture
of supraspinatus tendon, 65
S
Sappeys subareolar plexus of, 44
Saturday night
paralysis, 174
Scaphoid bone, 160

Scapula, 15
attachments on, 15
ossification of, 18
Scapulohumeral
rhythm, 81
Space
quadrangular, 69
triangular
lower, 69
upper, 69
of Larry, 191
intercostal, 215216
Spence axillary
tail of, 39
Sprengels deformity of, 18
winging of, 38
Segments, bronchopulmonary, 246
Sheath/sheaths
fibrous flexor, 141
synovial sheath, 142
digital, 143
radial bursa, 143
ulnar bursa, 142
Shingles, 217
Sibsons fascia, 188
Sign/signs
Dawbarns, 79
Foments, 144, 181
Sinuatrial node, 272
Sinus
coronary, 286
of Valsalva, 286
pericardium, 257
oblique, 258
transverse, 258
Sinus venarum, 264
Snuff box anatomical, 157
Space/spaces
dorsal, 158
forearm of Parona, 154
Larrys, 194
midpalmar, 153
palmar, 151
pulp, of digits, 154
quadrangular, 69
thenar, 155
triangular, lower, 69
triangular, upper, 69
Sprengels deformity
of scapula, 18
Sternum, 196199
Struthers ligament of, 22
Students elbow, 130
Superior vena cava, 283
Sulcus
of heart,
329
330
Index
uploaded by [stormrg]
coronary, 263, 276

terminalis, 272
Supination, 134
Sympathetic trunks
thoracic, 306
Syndrome/s
carpal tunnel, 139
Guyon tunnel, 150
Horners, 56
mediastinal, 254
painful arc, 79
Pancoast pain, 235
thoracic inlet, 194
ulnar canal, 150
T
Tachycardia, 280
Temponade, cardiac, 259
Tendon, of infundibulum, 272
Tinels sign, 178
Thoracic cage, 185
Thoracic duct, 302305
Torus aorticus, 265
Trabeculae carneae, 266
Trabeculum, septomarginal, 266
Trachea, 292294
microscopic structure, 293
Tracheal
shadow, 294
tug, 288
Tracheoesophageal fistula, 299
Trapezium, 30, 31
Trapezoid bone, 31
Tree, bronchial, 241
Triangle
Koch, 265
of auscultation, 62
Trigger finger, 142
Trigonum fibrosum dextrum, 272
Trigonum fibrosum sinistrum, 272
Triquetral bone, 162
Trunk,
pulmonary, 290
Tubercle
intervenous of Lower, 265
Tunnel
carpal, 139
cubital, 180
Guyons, 150
ulnar, 180
U
Ulna, 27
attachments on, 23, 27
ossification of, 29
side determination of, 27
Upper limb, 1
development, 3
parts, 2
transmission of force, 4
Ulnar artery, 112
Ulnar nerve, 9, 115, 178181
V
Valve
cusps of, 269
cardiac, 268271
surface marking, 271
eustachian, 265
mitral, 268
of coronary sinus, 276
of heart, 268
semilunar, 269
thebesian, 265
tricuspid, 268
Varices, esophageal, 298
Vein/veins
accessory hemiazygos, 306
axillary, 52
azygos, 305
basilic, 56
brachiocephalic, 283
cardiac
anterior, 278
great, 276
middle, 276
small, 276
cephalic, 86
hemiazygos, 306
left brachiocephalic, 283
marginal, right, 278
median cubital, 87
median, of forearm, 88
of heart, 276
of left atrium, 261
oblique of left ventricle, 276
of Marshall, 276
right brachiocephalic, 283
Thebesian, 278
Vena cava
inferior, 285
obstruction, 285
superior, 283
tributaries of, 283
Venae cordis minimi, 264
Ventricle
left, 266
right, 265
infundibulum of, 267
Vertebrae
thoracic, 204, 209
atypical, 206
eleventh, 207
first, 206
ninth, 207
prominens, 211
tenth, 207
twelfth, 207
typical, 204
Vincula
brevia, 143
longa, 143
Volar carpal ligament, 139
Volkmanns contracture, 114
W
Waiters tip hand, 56
Whitlow, 154
Winging of scapula, 38
Wrist, 115
Wrist joint, 161
Wrist drop, 174, 175
X
Xiphoid process, 198

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TEXTBOOK OF ANATOMY

UPPER LIMB AND THORAX

Vishram Singh, MS, PhD

Textbook of Anatomy: Upper Limb and Thorax, Volume I, 2e

Preface to the Second Edition

Preface to the First Edition

Introduction to the Upper Limb

Bones of the Upper Limb

Back of the Body and Scapular Region

Shoulder Joint Complex (Joints of Shoulder Girdle)

Elbow and Radio-ulnar Joints

Joints and Movements of the Hand

Major Nerves of the Upper Limb

Introduction to Thorax and Thoracic Cage

Bones and Joints of the Thorax

Thoracic Wall and Mechanism of Respiration

Pericardium and Heart

Superior Vena Cava, Aorta, Pulmonary Trunk, and Thymus

Trachea and Esophagus

Multiple Choice Questions

The upper limb is the organ of the body, responsible for

1. Appearance of joints permitting rotatory movements of

Fig. 1.1 Position of limbs: A, in quadrupeds; B, in humans.

Textbook of Anatomy: Upper Limb and Thorax

that of hand is far more than the extent of an injury. Therefore,

The upper limbs are connected to the trunk by a pectoral

N.B. Only one small joint (sternoclavicular joint) connects

PARTS OF THE UPPER LIMB

The shoulder region includes: (a) axilla or armpit,

Fig. 1.2 Parts of the upper limb.

The wrist consists of eight carpal bones arranged in two

Introduction to the Upper Limb

Table 1.1 Parts of the upper limb

Hand proper (metacarpus)

The hand proper consists of five metacarpal bones

The subdivisions, bones and joints of different parts of

COMPARISON AND CONTRAST BETWEEN

as arm, forearm, and hand respectively in the upper limb,

Hip girdle/pelvic girdle

Textbook of Anatomy: Upper Limb and Thorax

Fig. 1.3 Development of the limbs.

Table 1.3 Differences between the upper and lower limbs

Prehension (i.e., manipulation of objects by

Locomotion and transmission of weight

Smaller and weaker

Larger and stronger

Smaller and less stable

Larger and more stable

Smaller and attached to smaller bony areas

Larger and attached to larger bony areas

the development, the ends of limb buds become expanded

TRANSMISSION OF FORCE IN THE

Introduction to the Upper Limb

Forces of the upper limb are transmitted to the axial

BONES OF THE UPPER LIMB

MUSCLES OF THE UPPER LIMB

The muscles of upper limb include (a) the muscles that

NERVES OF THE UPPER LIMB (Fig. 1.5)

Fig. 1.4 Transmission of force in the upper limb.

The axillary nerve supplies the deltoid and teres minor

Flowchart 1.1 Lines of force transmission in the upper limb.

Textbook of Anatomy: Upper Limb and Thorax

The musculocutaneous, median, and ulnar nerves supply

N.B. All the intrinsic muscles of the hand are supplied by